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BOX 1
00029
6
16
00029
-- -„" r..-- °- r- 7.- .,• -q+. -1 ,c..- .r- ..r.-
- PUTNAM COUNTY DEPARTMENT' OF HEALTH
n Division of En"vlropmenfal Health Servio* Carmel, N.Y 10512 Q
-. Freer Mart Pro"
sp C.H D PemltN
n
TE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
a,PXS�r
..p � f or
Located at N `(S
0 U-1 Cam: Z�'L Ta'MaP_ —Block Lot _' l_O
Owa� /ap�ir�et Name �ii)l �.1 f Q + i'► LN�V l S Formerly Snbdlvlabe Name O
MaWo�1e„ ?Znbrl�_ ',3s-�er Nl�zi� �a5oq subay..,,Lot 4
Fee Enclosed Amount..,# .100 , 00 Date Permit Issued 5 " q'-e)
Separate Sewerage System, built.
Y, h IJZ'5�
7G
'Comistip of OW Galion Septic Tank t : O
Water Supply: ft He Supply From q Addeew
. $fir YippB[ ► -ii
on PkWate SaPply DrIII by 1 YW 66
.o( *Asn- W ' Lot Size Z= Aas Erosion Cantrnl RPPn rimpl"PtPri9
e e �( 105f G
Uh
Number of •Bedrooms �l R
3 Hk Garbage Grinder Been ad!
Other Regalromenta y�
i
Tel n
I certify that the eyatea(,e) ',ae, isted_a inq t e above pieaieee were constructed essentially as a on she plans of the eta wo ( op3es
of which are attached), and in accordance with the
standards, rule r atio i actor i7Mth the liled'p an; and' the Pea,ait issued by the
Putnaa County Department fn, Health - - .
Data 5 :- —! Cortifk+0 by P.E. R.A.
Atltlreft'.
lloinas No
:Any parson occupying prninitet served pY. the above systems) shall :prompity take'sucg`aetion as nisy bi ns'- nr to seem the eonedbn of any aneanitary
conditions resulting ,from iuch.• usage: ;'.Approval .of. fM wparste sawe age bystam than'baoonta hull and void as aeon as pubt,z pottery sewer :begonias
available and the,spproval of the,piivate. water; supply Shell t►ecomf null a void wheal a public water :supply b000inss evaltable. Such approvals are
subject to 787". r!//JoW'Changa wMn; "in the judgment of, the Coin l nM of MM h, fu i oeatton. nadHlatlon or.ehww b "seamy.
Date . /,'.V.. BY TRM
��
3/89
0
I
. / / /'F.....
If
Office Use Only
CL
T)EPA.RVIE-N-T OF' It-EALTH
DI-vis"on Of EnvI.ronmenta.1 I(ealth Services
1vf COUNTY 1)7:,PARTK- �411' OF 'REA1,T14
TAA GRID NUM861.
WELL LG CATION
WELL r)WHER
NAME; A00AE33;
-2 0 PSIVATE
Io i i4 t,,_ 60 It4f -1 1 0 PUBLIC
USE OF WELL
0 RESIDENTIAL 0 PUBLIC SUPPLY 0 AIR/COND.IHEAT PUMP 0 ASANDONCO -
I - primary
❑ BUSINESS ❑ FARM 0 TEST/OBSERVATION 0 OTHER (specify)
2- secondary
0 INDUSTRIAL 0 INSTITUTIONAL ci STAND -BY 0
AMOUNT OF USE
YIELD SOUGHT PEOPLE SERVED j::' / EST. OF DAILY USAGE 6_0 0 gal.
HEAS0iFiW'__[_1Rj_3'PI.,ACP
EXISTING SUPPLY OTEST/OBSE, RVAT ION OADDTTIONAL SuPPLY
DRILLING
E]NF.W $UjIfILY (NEW DWELLING) rIDEEPFN EXISTING WFLlo
DEPTH DATA
WELL DEPTH, _A_05�__ft, STATIC. WATER LEVEL _&-LL it-1.1 f'DATE MEASU RED
F,
DRILLING
0 ROTARY 44 COMPRESSED AIR PERCUSSION 0 DUG
EQUIPMENT
0 WELL POINT 0 CABLE PERCUSSION 0 OTHER (specify),
WELL TYPE
0 SCREENED 0 OPEN END CASING 91 OPEN HOLE IN BEDROCK 0 OTHER
....................
.
TOTAL LENGTH ft
MATERIALS: 14 STEEL 0 PLASTIC 0 OTHER -
CASING
LENGTH* SELOW GRADE --ft.
JOINTS: 0 WELDED W THREADED 0 OTHER
DETAILS
DIAMETER 6 In.
SEAL: I& CEMENT GROUT 0 BENTONITE POTHER
WEIGHT
PER FOOT ---L-7— 1b,11t, I DRIVE SHOE. 10 YES 0 NO LINER: 0 YES IN NO
DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (it) DEVELOPED?
FIR-11 J,
Q YES ONO
DETA Ij_S
SECOND
10LIRS
GP,AV&r!.L PACK
YES GRAVEL DIAMETER TOP BOTTOM
0 NO SIZE: OF PACK __ In. DEPTH —ft, OEPTH — It.
if raor detailed formation descriptions or sieve analysts
WELL YIELD TEST It If detailed pumping WELI LOG are available, please attach.
METHOD: 0PUY?ED
I
1 tests were done is in- water Well
D E5:)UTRHFAF FROM m
IQ COMPRESSED AIR formation attached? gear, 0"'•
OTHER 0 YE-S 0 N ing m0cr FORMATION DESCIRIFTION coat
0 BAILED ❑
In
WELL 0&'TH CORAT10,11 DRAINCOWN YIELD Land
hr rnin. It.
_j L"L
J
nil
<7 '130
WATER 11 CLEAR
TEMP,
QUAL171 0 CLOUDY
HARDNESS
0 COLORED
ANALYZE07 OYES ONIO
ANALYSIS ATTACHED? 0 YES O NO
ST011ACE TANK: TYPE
Ck?ACITY _=�
WELL DRILLER NAME—T' DATE
PUMP "INFOR.MATION
TYPE
CAPACITY
MAYER
MODEL
DEPTH
VOLTAGE — HP
ADDRESS WGIMTURE
If
Boyd Artesian Well, Co., Inc.
R. D. No. 5 Rte. 52
Carmel, N.Y. 10512
(914) 225 -3196
JULY 18, 1989
4
WILLIAM F. LEWIS
22 BAINBRIDGE ROAD
BREWSTER, NEW YORK 10509
WELL.
RT. 292
PATTERSON
DEPTH:
CASING:
DRIVE.SHOE
TEST
i t
305' ® $7.00 /FT $2135.00
42' C 9.00 /FT 378.00 Vii
75:00-
8 GPM
TOTAL $2588.00
... ........................ ..... .
v
PUI'NAM COUN"L'Y DEPARTMENT Or HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
/ f
Owner or Purchaser of Building
Building Constructed by
Location — Street
Municipality
Building Type
I ( J-E-(o
Section Block Lot
&,J0
Subdivision Name
J
Subdivision.Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL 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 guarantee 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 iumediately following the date of approval of the
"Certificate of Construction Compliance" for 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 occupant.of the building utilizing
the system. Ato T 6v *jrI #u rr'F_ 14 �/� c�FSi (7r 5c� M f= ,p cl�2cz"' - Fitt ✓2�
-pj e Sty, ( OH 5c7iF — Oft' j,kP FA-c (V 2F
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environmental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occu�nt on theebbui�ing utilizing
the system.
Dated this day of /fzj 19,�,/) Signature
• Title
e__
Genera Contractor (Owner) - Signature
Corporation Name (if Corp.)
Corporation Name (if Corp.) �j S� ►�� 5�
Add
/2 V3 ,moo %l�s.y.,2s�� �'o�sy7�Q ✓d
Address
rev. 9/85 r S V !3 5 .F6U c(T }c%T /Y �Z
mk -D. ..JK• a s r to i45 s-r� /lfvv. �v /4 f� t (,u �S
/UI q11 � /i¢TZv il% t��
NYS: =F LAP ` #'1010$' °COUNTY- OF'WESTCHESTER` r E -'11 Rev 89
?OEPARTMENT'OF LASORATORIES.ANp >RESEARCH
.-VALHALLA. NEW
'YORK 10595'_
BACTERIAL..�X ATION OF ORINKING AND, TREATED (WATERSp
I Lab `:No W - Bottle No:
ie.t 17 .sus
i
Date Co11;d Time
Lab ;No ENT- E
Time Set lime Submitted
i Teats iCirclej: ^SPC Coliform MPN Coliform Membrane Fecal Other
Con`d by' µLAgency Coll d for`
Atldresa
. "
(St'. Ad.) RW.000q It:aunMl
IdenUhcatlori of Source" /
Sampling Point within`Premiasa ' y Refrigerated?
m /I. T0181 m /I y
Chlonnatsd? -Yes o' No o Frse 9 � 9 PH ,
RESULTS OF EXAMINATION OF WALER
MPN /100 ml Standard Plels Count'F ,J!
t Bactena, per ml (4'9
Coliform Group
r
� Membrane Method /100 ml
h Number PositiveTub" 'Total Cohfo►m
F Fecal CoUfocm, Other
Thai raulte_IndlcaH aampgf "wu, ivu not) of` Reported by
aatfefaetory eanitary qudity whrfn tM aampla wa +`
collaoted
n
. At190
rL
W Y D
wr,LL kjVr1r1Lz11V11 Arruml
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET AOURESS: wN /vt ! 1 Y TAX GRID NUMBER:
��, �`I�- 404 '% "
WELL OWNER
NAME: / ADDRESS:
W' [cc Le CRTs a� Baltib1-1 0kodo I iY2cudBm
® PRIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
® RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT L5 gpm. /NO. PEOPLE SERVED - / EST. OF DAILY USAGE SO tJ gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
®NEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
' WELL DEPTH S ft.
STATIC WATER LEVEL ft.
DATE MEASURED
DRILLING
EQUIPMENT
❑ ROTARY IA COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING 10 OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH ___. ft.
MATERIALS: §4 STEEL ❑ PLASTIC O OTHER
LENGTH BELOW GRADE_ ft.
JOINTS: ❑ WELDED M THREADED ❑ OTHER
DIAMETER 6 in.
SEAL: 19CEMENT GROUT ❑ BENTONITE ❑OTHER
WEIGHT
PER FOOT �LOL Ib. /ft.
DRIVE SHOE 50 YES ❑ NO
I LINER: Q YES P9 NO
SCREEN
DIAMETER (in)
'SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (ft)
DEVELOPED?
DETAILS
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
❑ YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST I If detailed pumping
METHOD: ❑ PUMPED i tests were done is in-
(Q COMPRESSED AIR , formation attached?
O BAILED ❑ OTHER ❑ YES ❑ NO
1�I�LL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Hear-
tag
well
Oia-
meter In
FORMATION DESCRIPTION
cant:
ft.
tt.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
Surface
.'LCI,t Q �` G
Al
k 17
IW0LKzj",1A_
a4,.-
70
�lb�t
a4
„a.�
O CLOUDY HARDNESS
O COLORED ANALYZED? O YES ❑ NO
NALYSIS ATTACHED? O YES O NO
[MAKE ❑ CLEAR TEMP.
STORAGE TANK: TYPE
CAPACITY GAL.
INFORMATION
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME-B" A , �A,l� )tU_Co V DATE 0
ADDRESS �¢ FS-� SIGMMRE
e-0 L K4 Q'I 0s-,
si 0y I "'/
"s
STP,E�T LLC3TION '
Pt MJ T 24 a OR - SUEOMSiOi wr a
I. Eire_ E DISPOSAL P.Rt.3
a. SDS area lccat=--3 as per . amroved plans
b. Fill. sectim - Date of placaru nt
2:1 . barrier . I= W-= P_VG _ DPTH
c. Natural soil not s: =i =.---3
d. Stone, brush, etc-, great =T t-ian 15' from SDS ar e--
e_ 100 ft. from wat=r course /wetlands_
II_ S1 DISPOSAL SYSIEM
a. S?*oLC tank size .1 r 1,250
b. Sentuc tank ins1 =T e3 level
c. 10' minimmm from fcundat?cn
d. NO 90" be_ncs, cl-e:*gout within 10 f_. of 45° b--nd
e. D:l:S=Tj- -TICN BCX
1. P-11 cutlets at same eliaiTction - watIIr tested
2. Prot =�� belcGi frcSt
3. Minim= 2 ft. cri cL n.`7 saill be =, e=*1 bcx and
f. Ju=ION BOX - crLme-m-ly set
g_ 5
1_ I*zq= r==u? r
2. Dist.-ncs to watarcaur c me cLr= + it.
3. a^--norc? nq to Dln
4- Distance cent-er to C='1 Lan
5. Slor� of t_e_zch accent=_ble 1/16 - 1/32
E. 10 feet from prep- ty line - 20 i �t
7. Dent:n of tr`hch < 30 Lnches from ssr =rte
8. Roan a l—1 awed for excan c i cn, 50 •`b
9. Size of c rJZ 3/4 - li" cia-net_*-
10. Deot:h of crye? Ln t=ech 12" mLn.?.,* m
i . - Pipe ends ceDc;i
h. P OR DOSE SYSM—S
1 Size of v =. c =be*- a- j
2. Over-1cw tank
k r
3. Ala=, visa =? /aL:di o
E Pump eas l y acC.a_4si hle sannole to c de
5. First box be f =1
G. C:vcle w_the - = =s- by Eeallth Dew
estimat-- flow came
N. fiCk I
a. E^use loC✓ted Dex a:vorcved plans.
b. Number of be =rcars
V.
a. i -a 1 locate= as r-,--- a*- -orcved Mans
b. Distance from SDS ax-ea ma-asured ft_
c. Casing 18" above grade_
d. Surface d_'"-±P=-ce a cund well acceptor e.
VI. OLD -t`?i, WORKMA.SHI . -
a_ rxxas Drooe_-ly crcuted
b. All pipes TF-'-aai i y b c3cfled
c. pit pines witn inside of box
d. —;z=ckfill irat -arial contains stones < 4" in diameter
e- C twin drain installed according to plan
f _ C �, a i n d=in cut =all. crot -- -ted & dir. to exist_waterC
g. Frotinq dra ? ns d- senor ge awav fran SDS area
h_ Surface wat°_r- Drotec.-tion ade uate
i_ E=oszen crn`-o proved--,' on slopes crztar than 15$.
I
I TI
I --ICI
-I
i I
-H
�I
--r
4
-I
i
I
i -
r - _
.J�a -ao - .,a.� .,ran- Qua -�la"
ilal?o q,, As aw,
ov. -kz ,t4 ce)
y
i
p c=- - DZ{
Din_ "'`IT CF REA F T - DIz1ISICI Gr E'15J L r [ �••- c=
'tit- = Su-P°L-Z & c- ,ZcLp�zr�' �Tit pL= i-Cc�L S SZ�c
- -- c•TC=-E-.tc
i0 ft. Ao
=; l ncteE c
n_. s-ce:: .
CD:1S pZ TCN P=-II-TT
Elv-
C-L -CL-3 I I I
lCe v:. fiCCC I V I I
' I I
E'G - -T'.
Ver _ar—
_�`- 1E:RAT.
-EM Plan
��.YG•+- C "vC ern GcTV = -:i '� u -� _� �:_�J__- . -..
Fil i �F_of�'_� & Di erls, ; =S
l,.�i:�t_�.- .'..�_C:n Nct=S ('�.-_:1G°.r rate)
pert ard; C= res:_.. =s
Tvo-?xt Centaur= & prcxs
DriVega,v & Slcces Cat
C,ra_ns (� =c �:�ge Cam:
•p- ��� & -L�c =D eel _s L�;r.� _� � _
Re_ r== an a i ve c F pr -.�'^ ar-d
R,C- I _ -3r�ic _ f1cw'suff. SIZE
R ±Tm�-: Pit&
D F.cx Cilcvii & LL _il
Ecuse - NO. cf
we-Lis & S--S's w /_� 200 t .
nT�T f� Met ..
_eS &�..�.� -L�.
Ecuse Se c'{ NeC=.ss ar i Ml cht lct)
No Be-nip,; vm—a c. Eena-= 45° Wc_E a ut
CLD-�,R�^-s'T_ N. DISTL.% —= CV "TAN
Fi e-cc
10' to P.L. Drivega—v, T Z -e T= =s,Tc: Cl: =
20' to Fc-unc tic, oval"
100' to ;viell; 2001 in D.L.O.D, 1-50 ` pi
100, to St-Z -=-M S t_r u- =e, r >>e
151 to 'Dr -! ns Ca -ai - ^., Laai.2 -", FCCt:r1;
35't.^. CSC 1 -
10' ro Water Line (�i= = -?'(9 )
LQ 1 L= , F,:, iII =_i . i =l� 1 iC waL
I permit p��l i ca t� cn�°`
Ccr,-.,cret =- RIP-scl ut_C,
I Plans _
ac._ Lcc
I Ccrs_ scan c Per` Pte= _ =r (3)
I L
° I
i
I I
C-L -CL-3 I I I
lCe v:. fiCCC I V I I
' I I
E'G - -T'.
Ver _ar—
_�`- 1E:RAT.
-EM Plan
��.YG•+- C "vC ern GcTV = -:i '� u -� _� �:_�J__- . -..
Fil i �F_of�'_� & Di erls, ; =S
l,.�i:�t_�.- .'..�_C:n Nct=S ('�.-_:1G°.r rate)
pert ard; C= res:_.. =s
Tvo-?xt Centaur= & prcxs
DriVega,v & Slcces Cat
C,ra_ns (� =c �:�ge Cam:
•p- ��� & -L�c =D eel _s L�;r.� _� � _
Re_ r== an a i ve c F pr -.�'^ ar-d
R,C- I _ -3r�ic _ f1cw'suff. SIZE
R ±Tm�-: Pit&
D F.cx Cilcvii & LL _il
Ecuse - NO. cf
we-Lis & S--S's w /_� 200 t .
nT�T f� Met ..
_eS &�..�.� -L�.
Ecuse Se c'{ NeC=.ss ar i Ml cht lct)
No Be-nip,; vm—a c. Eena-= 45° Wc_E a ut
CLD-�,R�^-s'T_ N. DISTL.% —= CV "TAN
Fi e-cc
10' to P.L. Drivega—v, T Z -e T= =s,Tc: Cl: =
20' to Fc-unc tic, oval"
100' to ;viell; 2001 in D.L.O.D, 1-50 ` pi
100, to St-Z -=-M S t_r u- =e, r >>e
151 to 'Dr -! ns Ca -ai - ^., Laai.2 -", FCCt:r1;
35't.^. CSC 1 -
10' ro Water Line (�i= = -?'(9 )
LQ 1 L= , F,:, iII =_i . i =l� 1 iC waL
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #P-2-249
WELL LOCATION
Street Address
5 ,�-8 �� � d�
To Villag Cit
T r�
Tax Grid Nu ber
/ - l - T . l
Name Mailing
a)11-L l lLr,
Address
AAOI 0
mtrivate
%2X O Public
:SE OF WELL
1 - primary
2 - secondary
SIDENTIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED
11 BUSINESS O FARM . O TEST /OBSERVATION O OTHER (specify
0 INDUSTRIAL []INSTITUTIONAL O STAND -BY' O
AMOUNT OF USE
YIELD SOUGHT gpm /#
PEOPLE SERVED /EST. OF DAILY USAGEZa2/' gal
REASON FOR
DRILLING
O,REPLACE EXISTING SUPPLY
6ANEW SUPPLY NEW DWELLING)-
O TEST /OBSERVATION GI ADDITIONAL SUPPLY
D DEEPEN E ISTING WELL
DETAILED
REASON FOR
DRILLING
1Ze5 • &
WELL TYPE
' DRILLED
DRIVEN
0DUG
GRAVEL. D OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ✓� NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Ah
Lot No.
WATER WELL CONTRACTOR: Name • f 1267 _ )1 A_)EZ31 Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH& SOURCES OF CONTAMINATION PROV D
/ h ®ON SEPARATE SHEET
(date) 1 (si nature
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted vinder the
provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and
provided that within thirty (30) days of the completion of water well construction,
the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam
County Health Department attached to this permit.
3. Submit a Well Completion Report on-a form provided by the Putnam County
Health Department. � � �rl�� ,
Date of Issue: 19
Date of Expiration: 19 L
_v Permit-ing�licia
Permit is Non - Transferrable
Rev. 10/88
White copy: H. D. File
Yellow copy: Building Inspector
Pink Copy: Owner
Orange copy: Well Driller
PU11M CC= DEPARTKENT OF .
DIVISION OF •' i' ' M Y• HEALTH SMMCES,
DESIGN DATA SHEET- SUBSUFACE SEDGE DISPOSAL SYSTEM FnZ NO.
owner Address PLO. (30), g4 do is , IV`(. 1150/
pop
Located Located at (Street) N_i. R i-e 292 See. 1 Block t Lot 5 tD
(indicate nearest cross street)
Municipality -TbVm D K - Watershed C✓o -� r.
SOIL PERCOLATION TEST DATA P37J M TO BE SUBMITTED WI'Tfi APPLICATIONS
Date of Pre- Soaking ml (0(136. Date of Percolation Test IZ 1 6) 66
HOLE
NUIJBER C= TIME PER0a=ON PERCOLATION
Run Elapse= . Depth to Water From Water- Level
No. Time : ' Ground Surface In Inches Soil. Rate
LOT O3 Start -Stop Min. - Start Stop Drop In Min /In Drop
Inches Inches Inches
1 I :615 '2 :4( 4&
1 � 2 Z :qz• 3:3o q8
3 3:3t -4:I9 *s
0
5
�2 J 1 /•�6- z'
I.,
Z/
Zf Z
ZQ 2(
e
■
■
�i
2 x:93 - 3:3 I
4t5
Z4 2 l
3
16
3 3:32- 4:2
32
A 2(
3
t g
4
5
,
2
3
4
5
NOTES: 1. Tests to be repeated at same depth until apprcximately equal soil rates
are obtained at each percolation test hole. All data to* be submitted
for review.
2: Depth measurements to be made frcm top of hole.
Loitt3
DEPTH
G.L.
2'
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES_
HOLE NO. HOLE NO. 2 HOLE N0. .
i'o�.SolG
Z5'
31 C44Y 10.40
4' v b
5' i--4 Lai#
i.71
8'
9'
. 10'
- 11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNUATER IS ENCOUNTERED 4
INDICATE LEVEL 7U WHICH WATER LEVEL RISES AFTER BEING ENOOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: P,E , DATE: It ZA
- DESIGN
Soil Pate Used (%'20 Min/1" Drop: S.D. Usable Area Provided SCOD .f4''
No. of Bedroans 4 Septic Tank Capacity gals. Type CO064d e
Absorption Area Provided By L.F. x 24" width trench
Other 2i l�P..� n�Ei��a12TA iN 77i2� i til S . �O arG.Y.t.1,'� LE1�L�1��
• i —� � Lei{/ ?f
Na .L rJl'��J� r /�%r�21s sSS GC , �C . Signature
Nam 9
Address _ 7•� �%��l% -� r-1 L:--E 7P I lh% SEAL
AA
sod /l)-Y
• .. S4A No.
THIS SPACE FOR USE BY HEALTH DEPARDEM ONLY:
Soil Rate Approved sq.f%,% 1. Checked by Date
WiliL kjUrLrijF111VV4 rUXUAl
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADORESS: TAX GRIO NUMBER:
_P0
WELL'6WNER
NAME; ADDRESS:
a ko "TIN
e a);s A9 to q(
PBIVATE
❑ PUBLIC
0 PUBLIC'
`-'USE-OF.WELL
:primary
E,Z- secondary ,l
0 RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/CO.ND.IHEAT PUMP 0 ABANDONED
0 BUSINESS 0, FARM ❑ TEST/OBSERVATION 0 OTHER (specify)
❑ INDUSTRIAL 0 INSTITUTIONAL 0 STAND-BY ❑
A M 0 U N T,,,O F USE
YIELD SOUGHT L gpm./NO. PEOPLE SERVED L EST. OF DAILY USAGE sV 0 gat
REASON FOR
DRILLING •
.[]REPLACE EXI STING 'SUPPLY ❑TkST/OBSERVAT'ION []ADDITIONAL SUPPLY.,,:
E"R, SUPPLY_ (NPW0DWELL I G).
DEPTH DATA
WELL DEPTH S ft.
STATIC WATER LEVEL ft.
DATE MEASURED
DRILLING
:EQUIPMENT,
-0 ROTARY 1A COMPRESSED AIR PERCUSSION ❑ DUG
0. WELL POINT 0 CABLE PERCUSSION O OTHER (specifft,
WELL TYPE
0 SCREENED 0 OPEN END CASING IN OPEN HOLE IN BEDROCK . 0 OTHER
CASING
.-DETAILS
TOTAL LENGTH tL
MATERIALS: 9 STEEL 0 PLASTIC 0 OTHER
C
LENGTH BELOW GRADE.' ft.
JOINTS: 0 WELDED' 69 'THREADED 0 OTHER'
DIAMETER, b in.
SEAL: 19 CEMENT GROUT 0 BENTONITE ❑ OTHER
WEIGHT
PER FOOT lcl 1b./ft.
DRIVE SHOE. ES
1A Y
ER'O YE S
LINER`. INNO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH
(11)
DEPTH TO SCREEN (It)..
DEVELOPED?
FIRST
OJES.. 0 No
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK -in.
TOP
DEPTH ft-
Borrom
DEPTH It. '
WELL YIELD TEST I If detailed pumping
METHOD: 0, PUMPED i tests were dbne is in-
IQ CQMPFESSED AIR formation attached?
0 BAILED ❑ OTHER 0 YES' 0,NO
WELL LOG
I
It more detailed formation'descriptions or sieve analyses
are available. please attach. .
DEPTH FROM
SURFACE
Water
Bear-
well
Dia-
mete
In
FORMAnON DESCRIPTION
Mae
WELL DEPTH
It.
DURATION
hr, min.
DRAWOOWN
ft.
YIELD
9pm.
Land
Surlace
d -t C,,[a-U 0 Vt4-W C&4
L
)
go,
Aor
1 11
go
70
aqa
J..
&.Q2 A4
WATER 0 CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? 0 YES ONO
ANALYSIS ATTACHED? 0 YES 0 NO
STORAGE TANK: TYPE
CAPACITY
PUMP INFORMATION
-TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE — HP
WELL DRILLER NAME—.B"d U Cc) DATE
ADDRESS P-f -.2, SIGMMRE
C —n � I os-
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11