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00127
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Street Address:
Town/Village:
Tax Grid #
Map Block Lot(s)
Well Owner:
Name: / Address:
Use of Well:
1- primary
2- secondary
AL Residential Public Supply Air cond/heat puifip Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion Compressed air percussion Other (specify)
Well Type
Screened Open end casing Open hole in bedrock Other
Casing Details
Total length ft.
Length below grade ft.
Diameter �in.
Weight per foot lb /ft.
Materials: Steel _ Plastic ,--Other
Joints: Welded Threaded _ Other
Seal: X Cement grout _ Bentonite Other
Drive shoe: X.- Yes No
Liner: Yes No
Screen Details
Diameter (in).
Slot Size'
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes—No
Hours
Second
Well Yield Test
_ Bailed _ Pumped Compressed Air
Hours
Yield &tgpm
Depth Data
Measure from land surface- static (specify ft)
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
sieve analyses
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
_
'N) Q.7 r.-
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
3�
Pump Type jkf &0 m ",,��apacity 10
Depth f op Fr Model 10 GS CS
Voltage 230 HP Yz,
Tank Type XX � RCS- Volume 6_ -RL
fQ3
Date Well Completed
ax /-
Putnam County Certification No.
Date of R ort
Well l5riper 'gnature)
NOTE: Exact location of well with distances to at least two permanent landmarks to be provide a separate sheet/plan.
Well Driller's Name Address: l /v�
Signature: Date:
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
-i7
5
'RENEWAL /
�- I0"7 PUTNAM COUNTY DEPARTMENT OF HEALTH /PER`�rrr- r
Division of Environmental Health Services, Carmel, N. Y. 10512
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM
Located at Route 311°
Subdivision
Owner Peter 01,Hara
Building Type H f 9 h Ranch Lot Area 75,731 s Q, f
Number of Bedrooms 3 Design Flow 600. 9 p d
Separate Sewerage System to consist of 900 Gal. Septic Tank.
To be constructed by to be determined
Water Supply: Public Supply From
Other Requirements
Patterson
Town or Village
Tax Map - 1 n Block 2
Lot 3 ^1 3 r 1 Job
Address Route 311
Patterson
Total Habitable Space i Square Feet
and —430 l.f. x 24" tile fields
Address
X Private Supply to be drilled by to be determined
Address
I represent that I am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules and regulations o the u nam
County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill
be •submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will
place in good. operating condition any part of said sewage disposal system tluring t e periotl of two (2) years immediately following the date of the issu-
ance of the approval of the Certificate of Construction Compliance of the o ' system or any repairs thereto; 2) that the drilled well described above
will be located as shown on the approved plan and that said well will be install accordance the sta ards, rules and regulations of the Putnam
County Department of Health.
Date 8 / 7 / 8 1 Signe P.E.X R.A.
Address Route 52, Carmel, N.Y. 0512 License No. 043880
APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless ruction of the building has been undertaken and is
revocable for cause or may be amended or modified when considered essary by the ommiss' of Health. Any change or alteration of construction
requires a new permitt. Approved for disposal of domestic sa s ag riv or su ply
Date ®,!� &1
By Title
a
a i RENEWAL PUTNAM COUNTY DEPARTMENT OF HEALTH
v (� Division of Environmental Health Services, Carmel, N. Y. 10512 - '
Patterson � ?/
9
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM
7 ~
Town or Village
Located Route 311_ Tax Map I) 0 Block l
Subdivision ,
Tax Ma pp #W l 3. 1 subd. 9
Owner Peter 0' Hara Address Route 311
Building Type Hi-Ranch Area 69,165 sq• ft. Patterson, N.Y.
,,Number of Pedrooms Design Flow n8-10 Min.. rate
a
Separate Sewera System to consist of ._.._9_011 - - -- Gal. Septic Tank
To be constructed by ___ _to..._b.e_ d et-ej-ai n e (
Water Supply. Public Supply From
Private Supply to be drilled by
Total Habitable Space Square Feet
and 3 6 0 ft. 2' trench / (' ) ( X )leaching pits
� 111 �R1�fr �Iil
Other Requirements
. Dryl-:T. Ord 'RGl_'1C31.nu
I represegt that 1 am wholly pnd completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal
system above described will be constructed as shown on the approved attachments hereto and in accordance with the standards, rules and regulations
of the Putnam clounty Department Of. Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commission-
er of Health will be submitted to the.Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the build-
er, that said puildIr. pill place in good operating condition any part of said sewage disposal system during the period of two (2) years immediately
following the date of the issuance of the approval of the Certificate of Constru tion Compliance of the original system or any repairs thereto; 2) .
that the dril)� wail described above will be located as shown on the appro an and,that sa' ell will be installed in accordance with the stan-
dards, rules and�r9gulationa of the'Putnam County Department Of Health.
Date 6/29/79 X
Signed P.E. R.A.
Route 52, Carmel, N.Y. 10512 043880
Address License No.
APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless construction of the building has been undertaken and is
revocable for cause or may be amended or modified when considered necessary by the Com ioner of Health. Any change or alteration of construction
requires a '"w pgrm`it. Approved for disposal of domestic S46,Nta
/;a:9e nd or � ater supply only.
g
e
0 ) kAR4
ACM PSOju
FII LD CHEICI: LIST
Date:
•Insp.by:
INITIAL SI`hE INSPECTIOTIT
Yes .
No
Comments
Property ].fines or corners found . . . . . . . ....
Can estimate house location
Will driveway ntsed cut
�
Must trees be removed -note these
Is deep hole representative of entire SDS area
Additional deep holes needed.. .
Sufficient SDS area available considering
driveway cut, house location, separation
distances, etc . . . . .
DEEP HOLE DATA
Depth.:
-
Water elevation: —
Rock elevation:`
Soils-description: 6A &16cn
Date: .
FILTU SITE INSPECTION Ins p. 'by:
House located where shown on approved plan
-... -_
SDS located where approved . . . . . . . ..
__._.
Length of trench measured
Width of trench average
Slope of the -line and trench acceptable ...
__.
Room allowed for extension trenches
Over 50 ft . from swamp, watercourse
Natural soil not stripped or SDS area
unnecessarily graded . . . . .
_
10 Ft. maintained from prop.line. and.
20 f t . From house . . . ..
Separation of trench from house, well
etc. follows plan . . . . . . .
_.
Nimiber of bedrooms checks . . . . . . . . .
Stories, brush, stumps, rubble; etc. greater
than 15 ft. from nearest trench . . . . . .
15 Ft. of peripheral soil horizontally from
trench... . . . . . . . . . ..
Junction boxes properly set
Could surface run off from driveway, roads,
.ground surface, etc. channel near SDS
area. . . . .
-
Does lot. drainage rarr.�car O.K. in area of SDS
FINAL GRADING OF SITE ACCEPTABLE
IR M=w cr>I•;cx stn,rT
j OD R ('u'00 IMoets Std.
Yes ' NO
R�ul1 iii
DOOM, t�1TS /
House plans O.K.
Da-sign data sheet
Peres presoaked?
Kin. 30" perc test depth
Remarks'
emark s '
Condt. results for 3 runs
D. Hole log O.K.
.Corporate Affidavit f'or other than individual
t
Authorization for engineer-
Letter from Water Supply if applicable
If variance requested -such noted on plans & apps.:
r
D TAILS
9 - if change is proposed,)
Existing contours shown kshow new contours)
Slopes for driveway cuts, -etc. shown
erQ!1jZ �
ILater service line location
zn '
Footing drain, etc. location
Top slope, bottom slope of fill
v .PLLL
Percolation tests and deep test pit location
i
Septic tank size and conformance to std.
j
3 B. R. house minimum
House setback shown
I f
Distribution box ftg. below frost
All water within 50 ft. of'PL shown
!
Plan and profile SDS .. . ( ....... ....... ... .
All other wells and SDS closer 200'
'shown or reference made '
Prope.rt� ,b,oundaries (metes and bounds - clearly shores
?PARATION DISTANCES SPECIFIED ON PLAN
1' to P. L.
' to Fovhdation wells
' to Nearest well
' to stream, march, lake, etc. incl
' to Curtain drain
' to water line (pits -201
' to storm drain
''to large trees
' froi�i foundation to septic tank
' to pipe from leader drain & .1'oa1 li%
.expansion)
i
;; c rain
__._.Peter O'Hara
Lota_
:?'lZ;.._ to `'. r_ .. Y rES T , ciu'Ll. >r_: c _.._ ._,._ _ George A. H a u g h n e Y
4
a1:)f'Yl �=ci pr'o__ >essicnial eI:C1ineer Tw rc,giste.red ari_itite, l
to irip lly fca- a Const:ruc icn. L for a Sepa -,.- tLc: 'c'wagF b3 se ; ti
Ul noted pro -i—p -e ty in accoraanc=e ri t'? 'Che 5: ta-j lords , Y•:.iies: r-
Iu-'oroul.agat d by the C(YiiTrJL-ssJ,oner of the ridtn.i:F. Co-Linty Di-�pr3Ttinent of H
to icln all necessary ry Nat)ers on my }`•c?hali in coi:n1 - -ction -with tIiis Tnati ', L
of sai_cw ,ysteiii or
y
Route 52
C -armeI ; N.Y. 10512 °''
(914) 225 -9353
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Located at (Street Sec. Block
6dicate neares cross s ree
Lot -3
Municipality 'p,j Watershed ►�j.p�
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
° Number CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water a er ve
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop . Drop in Min. /in drop
Inches Inches Inches
72-4 E> 240 Z1 I
2 7),.Z4 - 3 t 3Z. e>
3 3-'!L -- -7 2JZP
710
- 5
1
2
M
Y
5 -
1
2
3
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 measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS .ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
G.L.
6"
12"
18"
2411
30"
36"
42"
48"
54
60"
66"
7211
78"
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY T. �/, Date
DESIGN
Soil Rate Used• -io blwi "Drop: S.D. Usable Area Provided ScsC�v�—�
No. of Bedrooms j Septic Tank Capacity qoo Gals. Type
Absorption Area Proed By_3! U L.F.x24" width trenc .
Other
DiaL„c �c-z� A•�t� signature
`\```fit , .` ��'•i
Address 'Vc 3
.,
SEA P
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft/Gal. Checked b �'' ?` p 04JO°
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