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HomeMy WebLinkAbout0699DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23.12 -1 -15 / 23.12 -1 -16 �� II 1, .r ���',a,,, 9, . we I T 'A . 4 I r .� 1 WE" COMPLETION REPORT P.UTNAM COUNTY DEPARTMENT OF.HEALTH 3/71 Division of Environmentel 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 NAME ADDRESS Q_ "c-'s LOCATION OF WELL (o. 6 Street) (� (Town) (Lot Number) " S PROPOSED USE OF WELL T—BUSINESS 51-DOMESTIC ❑ ESTABLISHMENT ❑ ❑ TEST WELL FARM 11 SUPP Y El INDUSTRIAL AIR El OTHER CONDITIONING (Specify) DRILLING EQUIPMENT COMPRESSED CABLE a ROTARY ❑ A R PERCUSSION ❑ PERCUSSION ❑ (Spe (Specify) CASING DETAILS LENGTH ( feet) p� �p DIAMETER (inches) WEIGHT PER FOOT C, THREADED ❑ WELDED 5 O YES NO )MA CASING YES rJUTED? NO YIELD TEST ❑ BAILED ❑ PUMPED HOURS G.P.M. COMPRESSED AIR YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specifyfeet) t r- ' !• DURING YIELD TEST fleet) Depth of Completed Well 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 © 2© If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED ��jj4 DATE OF REPORT WELL DRILLER (Signature) I•�, :.5A:C-T.M,A'PERWL-,.' (Agra ' ld6-'.60unt-dt.350:C). COLIFORM.GROUP (Most pTobab.le No: /100m1.) : HARDNESS TO: TAL -ppm , THM 2 m 2 YORKTOWN MEDICAL LASORATO 01N C. NITRATES (as N) - ppm IRON, TOTAL'-; ppm P.O.. Box 99, 321. Kear Street 2 hHblghW,X-Y'j0598`- 53 77777777-7 DATE COLLECTED_ --'RESUL-TS*-0F.-EXAN-lN ATto W.0ir MATER OWNER DATE RECEIVED • '071Y-VILLiAGE TOWN .,'VQIWUAMt OF 'SUPPLY DATE REPORTED pq ON n GPOINT :.5A:C-T.M,A'PERWL-,.' (Agra ' ld6-'.60unt-dt.350:C). COLIFORM.GROUP (Most pTobab.le No: /100m1.) : HARDNESS TO: TAL -ppm , THM 2 m 2 .' DETERGENTS NITRATES (as N) - ppm IRON, TOTAL'-; ppm —4. M oU tiiT41 r4 ,1im w ROAD, 70W.&A Q pAITEj 2sokA Tm ,� �.�. 2. ,..J, I on 5 F PT +c• JA-`7 - AW<. ���►�� -� � w4 , box E� ss : �..._........_ _.... rjO .... ....... 2' — — -. -- `tea..._ .......,.... �,... 4ol -� AUG3 •1973 Imo" LA ¢ ►uTrJAM cull I F k}EA TH E.. IL O E. V SION OF ENVIRONMENTAL HEALTH SERVICU a MESA5URGMEA T A. hell,. aeociatca OYPanai•�e C.ar►su8tar�ts LRMEL., NEW YORK.1.061:: i. a. q. s To .A. ib. ig' U 40 49 (o o' A. hell,. aeociatca OYPanai•�e C.ar►su8tar�ts LRMEL., NEW YORK.1.061:: F -- -- • e f PUT NAM ,( 'D Vision of, rlw CONSTRUCTION IPE,Mmiir FOR SEWAGE DISPI V Laceted''at i i2L ' Si bdwis�on f BUii'0 n9 Type . i t�-N -Z +L_ot Ari C' d t „' W rF C aC: I*umber of BetlYogms -a x -a ' Separate Sewerage System bo fcbMitt of '' To be, constructed by r .. .. -.. Water Supply. r Public!$upplY�From��r ° �"`�!Prwatea5upply�to�be drilled +ti y p ., -,ry •„� � d.. ~i t' �Sz.s .431 Atldress _ Other- 'Reg UIrements 7. f3 r25 PER' DF, S , . 1' represent that'J'am wFjoll,y and completely responsible fo ifbove described wall be;constructe'dnashow;n onstheapprov 'County: ipepaQment ,of, ilrl lth,,!and that one completion t -be submitted to:;the Department, and a-written",guarant place ;iii "good •'o,peratingi>fcondition any'±partx of said °sew Ance ,cie the approval fcf -;the,Cert. icate ;of�, Cons`ttruction`• w✓�II be located asashawn on the approved plan and that said; County'Depa nt of Health f fl Date APPRO�/ED FOR' CONST,RUC7TI�ON � This ;Approval expkr revocable'for,cau§a or may be, amended or,modrfredwhern+ requires a new permd i4ppr ed for °disposal of dome r :'r; 1 y/ n + arr m1�TY �DEP�ART�IVIENT ,OF HEALT;H4 z : neural tHealth Sererces Ca"rn7 ! N Y 10512 L �YS�EM F s t, �a o w qA%T 4 �r . Y u t Q,N S T Block..._ Wow Spftiori aJob - s _ml -Ad Add "Tess �� a Total Habitable Space ���" Square Feet al,­ Sep Yicf gTarikr� ✓�Q 114nea1 feet „X width trench ZNE a Address _ - t rs .� v '� -t rr�.�' r w".� . 1 x. ♦ `4 n 4_- r� e y.'`� , l:A o' I! R 7'VC 2 T"E?sTt�'�r :7'o� G"E �': dCu�/�:;� i4F"T.ER �Rout�n; uJA>E1(, is Low�,cEri design and loceUon of!. the {proposed aystem(s); 1) that the separate sewage _disposa_I system. nendriment tthere to afid inm,acdordance with the standards, ru, es-and,regolations o._ .t e PI nam �f a Certrficate of Construe- ton'Compliance ^ sat�sfactory'to the Commissioner of Heallthwil ill be'furnithed the owner sh�s successors herrs!or' assigns by the -bu�ldeir „thatlsa)d budder will: iisposal� system during the per_iod.of'two (2,),Vears i'mmed.atelie following thedate of We issu- ipl ance of the on ' system or any',iipaWr ilierei6 2j'that the drilled'�well described above ._” will be instailed ccordance with the sta' Oar' ds sand r'egula. ,6nsof :the "Putnam =�` t a ' "'Lc, iense No.�: - "n` h4s en 4n8ertaken” and is, - �e >yearfr,om_Lhe ctate,rissued� unless construction of the bu�ld�,g s ;,_ - A dered!nec ssa y �by�he C m)ssi er' of Health r�Any, change; =or alteratio of +;;construction age and /o_r. + ivates `supply only � a a 11 PUTNAM COUNTY'DEPARTMENT OF HEALTH_ DIVISION OF ENVIRONMENTAL'HEALTH SERVICES' COUN'T'Y OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. S R ­513 7 . v. Owner Cora_ �a 14 Address- Located at (Street) (indicate t; ,Ew Sec . i Block Lot 7 neares cross street) Muni cipality",,,,y Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Run apse Depth to Water Water Level No. Time From Ground Surface in Inches Soil Rate Start. -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 1 REA G . �E�ST C'o uL o A10 7- QE 2 Q( UAJ B eC jUSE Of- 3 5 .. Notes: 1) Te'gts to be repeated at same depth until apppproximately equal soil rates are obtained at each percolation test hole. A. data to e submitted for review. 2) Depth measurements to be made from top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED VITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DP,PTH HOLE NO. G.L. SO(L- 6 L4 1811 Lj, 2411 3'611 361f HOLE NO. HOLE NO.- 8411 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE L T OH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MOM Date Ig. DESIGN Soil Rate Upqd op:. 1"Dr S.D. Usable Area Provided No. of Bedrooms Se-ptic-Tank Cap4cityV_66 Gals. Type 1CI45 /V Absorption o* r-ption A' rea Provided By 411 width trench. • 0 L.F.x2 Other Name z5ignaTure Addr e SEAL Au, THIS SPACE FOR USE. BY HEALTH, DEPARTPENT ONLY: Soil Rate Approved Sq. Checked by Date--- "gr>t"•'d� .., r. '}. y" =ssv ,g•b -r W? T+.."bt'RM .vraw' ':"5-y. �ji:. -'sr -, y. iipR' nor mmr'.v ✓it a i Al a:. i (.� w•�- r•K4z'RL [: t f?j.e I I ail 4� f 4, ? t t Y. R- ? i .'Fny at }Q ^✓5 } _ t� aca 4J -{ rr E �ac*.�yr t G 77th n. a 'a• , f,c, L.,!u I r.r 7 `t y Ft '� f z t ,y.a aF' �t;t ✓ -r"zC -,t.✓, I'-;n ✓z.. { r thf"v''4 ? y k !. }' �rt"c a - Pr : t .t T ;. - r w..4::• 5 ,� T i t . t, . } � Y . J 't 1 � ? 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