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Yorktown Medical Laboratory,. Inc..
321 Kear Street
Yorktown Heights, N. Y. 10598
(914).245-3203
Director: Albert H. Padovcni M. T. (ASCP)
J
LAB. N 1 306 =1 9.
Collection Station Used:
Carmel Peeksk.ill
Mt. Kis /..
_ Nev.City.
..Date Taken: /0100
Date. Received: 10
Date Reported:
Collected By: b'.
Referred By: _
Sample Source: ��
VL '7
LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF WATER
GENERAL BACTERIA
Standard Plate Count per 1.0 ml
(Agar plate @ 35 0C)
MEMBRANE FILTRATION TECHNIQUE (MFT)._
Total Coliform per 100.ml
Fecal Coliform per .100 ml
_ Fecal Streptococcus per 100 ml
MOST PROBABLE NUMBER TECHNIQUE (MPN)
Total Coliform:
Fecal Coliform:
OTHER ANALYSES
MPN Index Der 100 ml
MPN Index.per 100 ml
THESE RESULTS INDICATE,T AT THE WATER SAMPLE. ( � (WAS NOT) (NOT APPLICABLE)
OF A SATISFACTORY SANITARY QUALITY ACCORDING TO THE NEW YORK STATE.DRINKING
WATER STANDARDS,.FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
—a&4 A 4 C, - /'a 6-,1
Albert H. Padovani, M.T. ASCP), Director.
LEGEND
RDS - Recommend Disinfect -
ing Water Source
< - less than
TNTC = Too Numerous Too
Count
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 County Health. Department 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
NAMES
'�
ADDR SS
e a 3
LOCATION
OF WELL
o. a Get) own) (o Number)
St + 7, `
PROPOSED
USE OF
WELL
BUSINESS
19DOMESTIC ESTABLISHMENT ❑ FARM ❑ TEST WELL
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ ((Specify)
DRILLING
EQUIPMENT
❑ ROTARY
COMPRESSED CABLE OTHER
AIR PERCUSSION ❑ PERCUSSION ❑ (Specify)
CASING
DETAILS
LENGTH (feet)
a 0
DIAMETER (inches)
7
7/7 HT PER FOOT
�
THREADED ❑ WELDED
O
YES NO
YES
NO
YIEL TEST
❑ BAILED ❑ PUMPED
HOURS G.P.A.
COMPRESSED G.P.J
jQ7' S
YIELD ( ..�
1-
WATER
LEVEL
MEASURE FROM LAND SURFACE — STATIC(Specifyfeet)
/
DURING YIELD TEST (feet)
j
O
Depth of Completed Well v
in feet below, land surface: '?T
SCREEN
DETAILS
MAKE
LENGTH OPEN TO AQUIFER (teat)'
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.
FLEET to FEET
(
30 Q)
-�
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
DATE WE�'OM ,2!,ETED
VV
DATE F REPORT
J
WELL DRILLER (Signature)
. Qwner or Purchaser of Building
Building Constructed by
Location - Street
Municipality
Building Type
Ter, ti:on
Block
GUARANTEE 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 r.egulat.ions of the Putnam
County Department of Health,:and hereby guarantee to the owner, his success-
ors, heirs or assigns, to .place in.good'operating.condition any part of
said system constructed by me'which faila:to operate.fo.r 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 determin-
ation of the Director of the'Division of Environmental Health Services
of the Putnam County Department of Health as to whether or not the.fail-
ure of the system to operate was caused by the,willful or. negligent act
of the occupant of the. bu,ilding..utiiizing'..the system.
Dated this day of 19 Signatur
Title
Co orati Name if orp.
A dr
- - - - - - - - - - - - - - - - - - ----- - - - - - - - - - - - - - -
THREE (3). COPIES ARE REQUIRED.WITH THREE (3) CQPIES OF FINAL. PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO FILE NO_ TICE.OF DATE OF FIRST USE OF SYSTEM..
Division of Environmental Health Services, Putnam County Department of Health
y
-s.
h
k pnNAM COUNTY DEPARTMENT OF HEALTH_- DIVISION OF ENVIRONMENTAL. HEALTH SERVICES
INDIVIDUAL In1kM SUPPLY SUBSURFACE SOULGE. DISPOSAL SYSTEMS
/ Z_ FIELD INSPECTION REPORT
DATE.
INSP. BY: '
(Name of Owner). (Street Location)
INITIAL SITE INSPECTION YES NO OODMENI'S .
Wetlands on/or proximate to property ..............
Property lines or corners found.. ....
Can estimate house location .......................
Will driveway need cut....:...............
Must trees be removed - note these....._,_
Deep holes representative, of entire.SDS area......
Additional deep holes needed.:... .
Sufficient SDS area available.considering driveway
cut, house location,,separatlon distances etc.:.
Adjacent wells /septics... .:....
Access to prop6sed well locationfor
�drillin
D.H. - Deep Hole
G.W.- Groundwater
D. H. 1 . Lot, D.H. 2 'Lot ,z 'D.H. 3 Lot .
Depth to G.W. Depth to G. W. Depth to G.W.
Depth to rock Depth to rock Depth to rock-.
0 ft.
3 ft.
6 ft..
9 ft.
12 ft
'Soil Description
0 ft. 0 ft.
3 ft. 3 ft.
6 ft. ..6 ft.
9 ft. 9 ft.
12: ft. 12 ft.
FINAL SITE INSPECTION INSP. 1 o
'YES.
NO,,
CA S
House SSDS located per °approved..plan.... .
Length of trench measured < '
Width of trench average c�
Slope of tile line and trench acceptable,..:,.....
Roan allowed for expansion trenches.. ..........:..
Over 100 ft. fran watercourse ......................
Natural soil not stripped or SD ' area
unnecessarly graded ...................... .......
10 ft. maintained fran property line and"
20 ft. from house......... :. .. ..
Distance well to SSDS (ft.) L�
Number of bedrooms checks.....01
Stones, brush, stumps, rubble, etc., greater...r,o
than 15 ft. from nearest trench.. ............
15 ft. of peripheral soil horizontally
fran trench ..... ...............................
Boxes properly set... ..... ...... ..............
Could surface runoff fran driveway, roads,
ground surface, etc. , -channel near SDS area.. ��',:..��
Does lot drainage appear OK in area of SDS ..... :./
FINAL GRADNG OF SITE ACCEPTABLE.. .... .�/Z
.
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". i Vilutl'1 VVVI \11 LL'1l11 \i 1.1L:l1\1 Va' ALCUlLAJi.l
DIVISION OIL ENV7RONMEN'fAL 11CALT11 SERVICES
y
COUNIT OFFICE BUILDINU, CAI= -L. N. Y. 10512
D iSIGN DATA S1IEE'i'- SEFARATE SEWAGE DISPOSAL SYSTEM I FJ[LC No.
OwnerGerald VanCoughnett Address Harmony Rd. Patterson, NY
Located at (Street Mooney Hill Rd Sec• 1 Block •1 Lot 12
lindleate tiearest' cross a ree
t1wiicipality, Town of Patterson Watershed' Croton
SUIL mincoLA'PION TEST DATA MUMED TO BE SUBMITTED WITH APFLICA' IONS
l(ole
nT #3
Ilumber CLOCK TIME
PERCOLATION
PERCOLATION
Will
Blapse WpUli
to a er
a e� r Leve
Ilo.
Time
From Ground Surface
in Ir c1ies
Soil Bate
Start -Stop
Min.
Start
Stop,
Drop �n
Min. /in drop
'
Inches
Inches
Inches
159 - 29
30
21
4
7.5min /in
2 30 - 00
30
21
4
7.5min /in
19 - 49
30
21
2 3/8
12.�in /in
Il .
100 30 30 21 3 lUmin /in
2
231 - 01 30 21 3 10min /in
c - �� r .7/8
3 � r�. Tlr
Oi
Votes: 1) 'Pests to be repeated at same depth until aff�+poximatelyy equal soll�
rates are obtained at each percglatioti test hole. A11 data to a submitte
4or review.
2) Depth measurements to be made from top of hole.
9 � — 47 �--
10, i !,.•
o�p Ng X96,
12' M.. _
13 • F �y U�rl'
4i'i
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED N�A
INDICATE LEVEL Ta WHICH WATER IE'M RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY:' I.e- DATE: 6 6
DESIGN
• Soil Rate Used A0 .. i Min/118. Drop: S.D. Usable Area Provided Soad S�F,
No. of Bedrocros . 4' f Septic Tank Capacity /voo gals.. Type nip 2s /11
''...,777
Absorption Area Provided By' 444 L.F. .x 24" width trench
Other .2 !- /L�. R v& D `���%nua�u����ry tE�F NfW
Name !/6h%, ' Signatu;'�
J
Address _/ /✓ sEAt,';°P : i98'0 ** ti� ti r
�FESSICNP�
THIS SPACE FOR USE BY •HEALTH DEPARZM M ONLY:
Soil Rate Approved •scq•ft,/gdl.' Checked by Date
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