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BOX 8
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LI. o 1
,
00736
11 PUTNAM COUNTY ,DEPARTMENT'OF• :,HEALTH._ ,ENGINEER MUST
PROVIDE
Division of Environmental Heiaith SarvJoes, Cann% N . >Y ,110512 PERM It, # � loy— Sic
CERTIFICATE.,OF, CONSTRUCTION COMPLIANCE 0.014, "SEWAGE DISPOSAL SYSTEM
Town or ;Village
Located at 1 Tax Map 15.: Block
Owns ►.,. ,l iy • 'l�n,,n , cy 1J / Formerly �f Tax Map Lot, 0 Subd. rot
'IOU G l Separate" Sewerage System built by Address i
Consistl'ng of, L_'^! Gar. Septic Tank and _ � � I- -1f�J. �� Z4" t' CA
Other. requirements
Public Supply' From
Private Supply Drilled By
Water Supply:
Address ""' v 9
Building Type . �`�'�tP._i i 1 /u • No, of Bedrooms 3 Date Permit Issued
Has Erosion Control Been Completed?, Has garbage grinder been installed?
I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies
of which are attached), and in accordance with.the standards, rules, and regulations, in accordance with'the filed plan, and the permit issued by the
Putnam County De rtment Of Health: J
Oats Z Certified Dy P.E. - R,A.
..
Address & License No��.
Any person occupying premises served by the above, systems) .shall promptly take' such. action as may be neeessary secure the correction of any unsanitary
conditions resulting from such usage. Approval of: the separate. sewerage system shall become null and void as soon as a. public sanitary sower becomes
available and the approval of the private water - supply shall become null and void when a public water supply becomes svailabW Such' ;approvals are
subject to modification -or 'change when, in the judgment of the Commissioner of Health, such. revocation, modification or change la necessary.
Date BY Tif lw
v'
Rev. 6/85 .;:
p.nnu v� ,n /,uwq�J _ JWl /q Vf,t j
MODEL VOLTAGE fir . Wa i n ers . •Fa 11 /' f
PP g
DEPARTMENT OF HEALTH '" r
Division Of Environmental Health Services
PUTNAM t0UNTY•' DEPARTMENT OF IIEAL.Til
SIRE--f AOURESS: 10vrrtIVILLAGErC1IY (AX GAio nuradE,�:
WELL LOCATION
r _ 1 64 (I nt- 11� parr�r�nn. Y..
WELL OWNER
NA.UE: ADDRESS:
0
Buckingham Develo emnt Corp. C/0 Jerry Weisman, Brewster
FU6LICc,
USE OF WELL 0 RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /CONO. /}IEAT PUMP. O A8ArVD0NE0
1 - primary O BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify)
_ d -ry QINDUSTRIAL ❑ INSTITUTIONAL ' O STAND-BY ❑ i
,AMOUNT OF USE
YIELD SOUGI41' _ 75 gprn. /FIO. PEOPLE SERVED / EST. OF DAILY USAGE cal.
REASON FOR
-KNEW SUPPLY = ❑ PROVIDE ADDITIONAL SUPPLY O TEST/OBSERVATION
ORILLIING
❑ EEPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 201 It.
STATIC WATER LEVEL 2.1 � ft.
DATE MEASURED 9 -27 -86
DRILLING
❑ ROTARY .&I'VMPRESSED AIR PERCUSSION ❑ DUG
EQUIPMENT
❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify);
WELL TYPE
0 SCREENED O OPEN END CASING. ❑ OPEN HOLE IN BEDROCK ❑ OTHER
i
TOTAL LENGTH 24 ft.'
MATERIALS: IN STEEL O PLASTIC 0 0FE
LENGTH.BELOW GRADE 22 ft,
_
JOINTS: Ig WELDED ❑ THREADED 0 OTHE'
I CASING
DETAILS
DIAMETER 6 in
SEAL: ® CEMENT GROUT ❑BENTONITE OOTHER
WEIGHT PER FOOT � Ib. /ft.
DRIVE SHOE I&YES ONO
LINER: OYES ONO
DIAIJETER (in E
) 'SLOT SIZE LENGTH (H) DEPTH TO SCREEN (10
DEVELOPED?
SCREEN
DETAILS
FIRsr •
o YES 0 N
[SECOND
HOURS
GRAVEL PACK
O YES GRAVEL DIAMETER
TOP -
6050fd
O NO SIZE: OF PACK in.
OEPT11 ft.
DEFTH II.
WELL YIELD TEST II detailed pumping WELL LOG If more detailed formation descriptions or sieve analyses
are available, please attach.
METHOD: O PUMPED it tests were done is in- DEPTH FRO..f ,!!ally VI-11
formation altached? SURFACE Dia-
O _COMPRESSED AIR , seu. fOMMATION DESCRIPTI011 GoE
O YES O NO serer
O OTHER
O BAILED .
WELL DEPTH DURATION
DRAWDOWN YIELD Surlice
SEE ATTACHE.
It. hr, min. '
It. 9Crs1.
I--
WATER O CLEAR TEMP.
QUAL]rf O CLOUDY HARDNESS I
O COLORED ANALYZED? OYES ONO _.
ANALYSIS ATTACHED? O YES O NO STORAGE . TANK : .TYPE _.
PUMP IIIFORMATIOR CAPACITY_ GAL.
TYPE CAPACITY WELL DRILLER IIAME Falcon Well Serv1 , Inc.
Thomas W. Falciana„
p.nnu v� ,n /,uwq�J _ JWl /q Vf,t j
MODEL VOLTAGE fir . Wa i n ers . •Fa 11 /' f
PP g
Mitchell hollow Koad
Windham, NY 1.2496
(518) 734 -3987
FALCON WELL SERVICE, INC.
WELL LOG
11.0. Box 1.547
Wappingers Falls, NY .1.2590
(914) 266 -7305
Owner Mr. Jerry Weisman C/O Buckingham Dev. Corp.
Address Rt. 22 Box 377 Brewster NY 105090
Job Location Rt. 164 Lot #11 Town Patterson County Putnam
ICKNESS - FORMATIONS PENETRATED IDEP
4'
Overburden
9'
Very seamy ledge
111'
Gray sandstone with
Hammer
black & white
124'
Quartz
73'
Limestone
3'
Granite
Drilling completed 9/27/86
4f
Type of well b�2tQ-
Diameter
_
13'
Drilling Method
Hammer
_
124'
Depth pf well
201
ft.
Yield
75
gpm•
Drive shoe:
Static Level
21
ft.
197.'
Storage
180
ft.
201'
Storage
270
gals.
Use:
X
primary
secondary
X
private
public
Well driller
Thomas W. Fal.ciano, Pres
Well Casing
Diameter
6 inches
Total length
24 ft.
Below atade
22 ft.
Type
L7 lh_ GrPe1
Joints:
x welded
threaded
Sealed with
cement /grout
Drive shoe:
X yes
no
Comments:
Well driller
Thomas W. Fal.ciano, Pres
O7n'_eir__o_r__-Turc aser of Building
Buckingham Development Corp.
Building Constructed by
Lot 11
Location - Street
Town of PATTERSON
Municipality
1 family
Building'Type
Map 15
Section
4
Block
11
Lot
CONNTRY HILL ESTATES
Subdivision Name
�1
Subdv. Lot #
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
cons ; .tructed 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 success -
.ors, 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 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 Directar- 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 building utilizing the system.
17 NONEMBER , 87.
Dated this day of .19 Signature 94Y
Title
Corporation Name ( if Corp'. )
Address
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR, IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE'OF SYSTEM.
- - - - - - - - - - - - - - -
Division of Environmental. Health Services, Putnam County Department of Healt'
X Standard Plate Count'(CFU /1.OmL)`�
(Agar Plate @- 35 °C)
MEMBRANE FILTRATION TECHNIQUE (MFT)
X Total Coliform (CFU /100mL)
_ Fecal Coliform'(CFU /100mL)
_ Fecal Streptococcus (CFU /100mL)
..MOST PROBABLE.NUMBER.TECHNIQUE (MPN)
_ Total Coliform: MPN Index (per 100mL)
_.Fecal Coliform: MPN Index (per 100mL)
OTHER ANALYSES
REMARKS (For Laboratory'Use)
Sample Status:
(check each)._
Outgoing
_ Na2S203-
Incoming
_ LE 4 °C
_ GT 4 °C '
_ Other:
KEY FOR TERMINOLOGY
RDS = Recommend.Disinfec-
tion of Source• '
TNTC= Too Numerous To Count
CON Confluent '( -TNTC)
LT �. Less Than ( <)
GT = .Greater Than (�)
N/A = Not Applicable
LE 's LPRR t}ian er eeual 'to
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS (WASN'T) (N /A) OF A'
NE
SATISFACTORY SANITARY QUALITY ACCORDING TO TH YORK STATE DRINKING'
WATER STANDARDS, FOR THE PARAMETERS TESTED, AT'-THE .TIME OF COLLECTION.
12 /85(RvsdT /8T)RWE
For Lab Use Only:
_ H/C to
LAB OFFICE HOURS (Main Lab )': ,. ; '
9AM -5PM, Mon. -Fri.
9AM -NOON # Sat.
Yorktown Medical Laboratory, Iris
LAB _ �A• oo�s�a
321 Kear Street
Date Taken: 11/12/87
,. ,�� Time
Yorktown Heights, N. Y.10598
__
d: Time 77
Date Rc .
(914) 245 -3203
Date Reported:
Director: Albert H. Padovani M. T. (ASCPJ
Collected By : ail
T- FREGOSI, ROBERT -�
Referred By: ruckingham Dev.
DREWVILLE RD,
Sample Location: Lower eve a ro
BREWSTER, NY, 10509
Country Hill Est; Lot #11'
Patterson, NY,
Phone #P79 • ':z7TQ
J
Phone N
Sample Type:
L
Repeat Test? _
'(check one)
X: Potable _ _. '
_LABORATORY REPORT ON THE BACTERIOLOGICAL
QUALITY OF WATER
_ Non - potable
STP INF
_
STP EFF '
GENERAL BACTERIA
_
Other:
X Standard Plate Count'(CFU /1.OmL)`�
(Agar Plate @- 35 °C)
MEMBRANE FILTRATION TECHNIQUE (MFT)
X Total Coliform (CFU /100mL)
_ Fecal Coliform'(CFU /100mL)
_ Fecal Streptococcus (CFU /100mL)
..MOST PROBABLE.NUMBER.TECHNIQUE (MPN)
_ Total Coliform: MPN Index (per 100mL)
_.Fecal Coliform: MPN Index (per 100mL)
OTHER ANALYSES
REMARKS (For Laboratory'Use)
Sample Status:
(check each)._
Outgoing
_ Na2S203-
Incoming
_ LE 4 °C
_ GT 4 °C '
_ Other:
KEY FOR TERMINOLOGY
RDS = Recommend.Disinfec-
tion of Source• '
TNTC= Too Numerous To Count
CON Confluent '( -TNTC)
LT �. Less Than ( <)
GT = .Greater Than (�)
N/A = Not Applicable
LE 's LPRR t}ian er eeual 'to
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS (WASN'T) (N /A) OF A'
NE
SATISFACTORY SANITARY QUALITY ACCORDING TO TH YORK STATE DRINKING'
WATER STANDARDS, FOR THE PARAMETERS TESTED, AT'-THE .TIME OF COLLECTION.
12 /85(RvsdT /8T)RWE
For Lab Use Only:
_ H/C to
LAB OFFICE HOURS (Main Lab )': ,. ; '
9AM -5PM, Mon. -Fri.
9AM -NOON # Sat.
t
4 11 l
G
FAT, SITE LNSPE'C QN
1 1
TM z OR ScEDIt ISICV
DISpGS.AL P -RE?
I r C
y
10 . �t r O L'1 tr�1C _ l- " IILn � r• 1
VeL
9.. sas are lccal- '-^ as per an- croved la
L ce ends ccc�
I
h. Fl.XP CR DOSE SYSTEMS I
1. Size Of r= C"^•iL s•'r .
Fill sectica - pate cf PI cCr;ent
2. Ccz* =lcr, t=rk
r
2:1 b�rrieY . IG�'_ 4v P_�iG.DF
d P--m easi lv aC==ass ole Iran1 cl e to craEe
bat-1..711 soil nct stricce~3
I I
3_ Stcr_e, bryh, etc_ , Ci=te_r t-1E_:rl 15, f_an SLS a_rEa_
I
e_ 100 ft_ fran Twat_r ccur_ =A ec!anE_-. I
I-, . ter; DIEPCS ?L S-Zc
c�C t=_,Lti s- Z - 1, 000 1, 250
b. y`ct n c =-1 i cam, l I
�C ta_ 1C L • �_- _.._. 1. �� Z
C.. 10, � � --� f -GTr1 f c�: rcat.icn
C! a
d_ Ik, 90 bares, Cl == -lcLr_ w; Lnin 10 f�.. c_ 45 ba=rd.
e. DI5'r- �L_?'IGti ECX
1. All CLL Ets at- we -=r testa -'
2. Prot act=_` hel' O, r =Csz
3. r1i ZZ�- i'�I 2 z:._- cric? rl 571? Er-d t --.=n �S I
f. jt1t -i'ICN EOX set 1
1. L=nctz r==-, - L==: &-h. ins-tallez-
,2—.DlstVnce 't z: wit =-C-- Le rr = f = I
3. Lts l 1: cCC-- _i -- to plan
C . c_1-lter to cF_nter I
5. S_cce or t_.e .- zcc =ntab1e 1/17 - 1/32 I,/ cct.
6. 10 fe T f -= lime - 20 f=-=-- -
7. EerLn cr t=c ^_ch < 30 in -ches an sa =Gc_
8- Rom ailc+:er fcr ec nsi cP_. 50%
rr.
V.
vi.
u
0
n
'VL'
Size Or C c"vel 3 - f me_ r
I r C
y
10 . �t r O L'1 tr�1C _ l- " IILn � r• 1
VeL
Y A )
L ce ends ccc�
I
h. Fl.XP CR DOSE SYSTEMS I
1. Size Of r= C"^•iL s•'r .
I I
2. Ccz* =lcr, t=rk
I
3. P aru1, vi. / = is
d P--m easi lv aC==ass ole Iran1 cl e to craEe
I
I
5. First bcx ta:
I
I
6. Cticle witme_� ^. -i by Ecea L'1 Eecar me_nt
I
I
esti_�r�t� fic>r ur cycle
I
(i
EvLEE +
z_ EcLe lcc t_ re_r accrcved Plans.
I
+
I
b. N=.Ler Cr b-_�Ircrn_=
I
I
T1
a- we-11 lcct as a=rcve? ol= ^-
b. Dis -t2mce frarl SLS are= rr. = =s,'T� ft_
c. C__=inc lb" ahcv=_ cra,e.
I
d. Surface Arai n ^Ce arcLrG well
a. Ecx_ -s rcce-riv crcutE=
b. P.li pipes -rt-ia lv back =ii le✓
f
I c
c. Al 11 pipes f! L=1 with 1-11sice cf tc_i
I
( I
G. E c f ill r'�at =rid l ccnta? ns s zc.nes < C" in
e. 0irtai?7 drain accorr_l:ic to olan
I
I
f. C=. L in drain cut =ali prct =ct=,; & ci;.to
C_ r_ nc cr i= = _'"c` a,M;w; fray SDS `_
wcts_r r czt= _iCP_
i crcvi ced cn sl.cces cc
m _
r PUTNAM COUNTY DEPARTMENT OF HEALTH
R2 Division of Environmental Health Services. Carmel; N.Y. 1051? Engineer to Provide Permit p V
on CERTIFICATE OF COMPLIANCE, - 1.
CONS CTION P FOR SEWAGE DISPOSAL SYSTEM Permit q
Looted at ��{+ Town' or . village
Subdivision Name s Sabd. Lot N 1 1 Taz:Map �' Block !1= -Lot ► r
0 •� t ��A_µ .� , i P
Renewal .0 Revision ❑
Owner /Applicant Name t= �( 1Z
Date of Previous Approval
Maillug Address F— "— t - �i Town `ZIJGJ�. zip
Building Type'► 1 Lot Area
J. I, p /rt FW Section Only Dept) Volume
Number of Bedrooms Design Flow G /P /D fob PCHD Notification Is Requlre_ d When Fill is completed.
Separate Sewerage System to consist of � Z � Gallon. Septic Tank m
& f� ^)U.
To be constructed by -rP _R . 17 Address
Water Supply: - Public Supply From Address
or: Private Supply Drilled. by { .� 16. D _—Address
Other Requirements
represent t at tam 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,toand in accordance with thestandards, rules an regulations of
a u nsm
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 operafing.conditiori any part of said.•sewage disposal, system during the period of two (2) ion I m tliately to"owing thedate of the Issu-
ance of the approval .o7 the. Certificate of Construction Compliance of the original system or yan repairs r o; that the tlrilletl well tlescriDeC above
will be located.as shown on•the approved plan and that said well will be installed c rda whe s d s, .r les d regu a ions of the Putnam
County Depa ment of Health.
Date 2S Signed' P.E`_ R.A.
Adtl�ress License No
APPROVED FOR CONSTRUCTION: This approval expires a year f m the a issued less construction of t e building has been undertaken and is
revocable fpr ca a or y be :amended or modified when c' i ered eessar a Co' isston of Health. A y change or alteration of construction
requires a new permit A((FFproved for disposal of tlomes niter sewa nd/ priv e w supply only. /7F-
Date: �L^
-^ BY Title
0
Putnam County Department of fleal th
Division of Environmental Sanitation
AFFIDAVIT - CORPORATE CMNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
9
TO: Commissioner of Health - In the matter of application for
— — Construction ,permit for separate sewage system— — — — — - — — — — — — —
I, Jerry Weissman, V. Pres.— — --- — _ — — — — — — — , represent
that I am an officer or employee of the corporation and am authorized
to act for
(name of corporation)
having offices at Rt. 22, P.O. Box 377
Brewster, N.Y. 10509
_ ______ ____________ ___ ___ Whose officers are
President — Robert Frego_si — _ an — — _ —
Name d Address) — — —
Jerry Weissman
Vice - President _ _ _ _ _
(Name and Address)
Secretary--- -_ - - --
(Name and Address) — — —
Treasurer _ _ _ _ _ _ _ _ .
(Name and Address)
.and that I am and will be individually responsible for any or all acts
of the corporation with respect..to the approval requested and al-1 sub-
sequent acts relating thereto.
Shorn to before me this day Si ne
of / t.c�. --e-�� r 19 40 Title - e. e
Notary Public
DEBRA L. DeBETTA
Notary Public, State of New Yini
No. 4822461
Qualified in Putnam Cnu n� '{�r ''�
Comm6bion Expires �jTT 3-, % E
-Corporate Seal
J^
t i
-�
Is
QCA >C �.
PUTNAM COUNTY DEPAR'lMEN,r OF HEALTH
r DIVISION OF, HEALTH SERVICES
DESIGN..DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner eUCKiWOHAM ON. CC12p Address KT 22- la f,>r,, ! i 6Pz_ . N
Located at (Street) P-T I114 Sec. IeD Block 4 Lot I1
(indicate nearest cross street)
Municipality Watershed Mpol. h�1J
Date of Pre - Soaking Date of Percolation Test
l
OA
3
4
5
Siv�WATGN
NUM: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained at each percolation test .hole. All data to' be submitted .
for review.
2.. Depth measurements to be made fram top of hole.
rev. 9/85
HOLE
NLMER CLOCK
TIME
PERCOLATION
PE RCO MC
Run
No.
Start -Stop
Elapse
Time
Min.
Depth to Water Frain
Ground Surface
Start Stop
Inches Inches
Water Level
In Inches
Drop In
Inches
Soil Rate
Min /In Drop
1
Ci- 30
-3d
ZI.
24
30
(o
I .2
0-30
:3 c.-,
Z4�
( o
1 3
3rdU
2 i
o
o
4
O- �o
Ica
Z I
'14
3 v
10
I 5.
C; _ 3�v
o
Z
Z4
3y
10
30
Z i .
2 L3 �%4
4 3�4
I0.9 .
2 2
p- au
30
2.
-L .3
y- 3o.
3-0
ZI
23'�z
Zl2
lZ
Z 4
,25
p _ 30
30
�I
23j /z
V1
(Z
l
OA
3
4
5
Siv�WATGN
NUM: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained at each percolation test .hole. All data to' be submitted .
for review.
2.. Depth measurements to be made fram top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION'
DESCRIPTION OF SOILS EDK)OUN1ERED IN TEST HOLES g.
DEPTH HOLE NO. HOLE NO. 2- HOLE NO.
G.L. 'f �Gl11 Z ECx7 1 S MOP6011, f, UOT5
11 vAWDY LOAM 5AnlDY 0A-M
21 It ill
6'
71 II
81 It
90 It
10. It
11' I I
12' li
13'
14' C2 -7 I
11
h
k
II
II
I`
I`
.I
�I
2Oc r 7'
INDICATE LEVEL AT WHICH GROUND6+TATER IS ENOOUNTERED No e
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENOOUNI'ERED �-
DEEP HOLE OBSERVATIONS MADE BY :"` I DATE:
DESIGN
Soil Rate Used (o- M Min /1" Drop: S.D. Usable Area Provided
No. of Bedroans Septic Tank Capacity C gals. Type , 6E
Absorption Area Provided By L.F. x 24" width trench
Others
Name 7. W UAEJ LY+ P E Signa
t
Address 3OX 223 �5t-IU ,Y SEAL
. `�, l �✓ :.S
An
—Z L✓Nt
THIS SPACE FOR USE BY HEALTH DEPARZMENI ONLY:
Soil Rate Approved
sq.ft /gal. Checked by Date
DEPARTMENT OF HEALTH
Division Of Environmental H%a th Services
TWO COUNTY CENTER – CARMEL, N.Y..10512 (914) � 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
IS WELL SITE SUBJECT TO FLOODING? — YES _ NO
IF .WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
�srq Tc° LOT NO-: / I
WATER WELL CONTRACTOR: Name Fg /ca,v Ll/e / /Se /vim Address: /°D,
wAOOiNCers • FgJU
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: w YES NO •'
NAME OF PUBLIC•WATER SUPPLY: - TOWN /V /C
DISTANCE TO PROPERTY FROM NEAREST WATER•.MAIN 1 ,
..LOCATION SKETCH & SOURCES OF CONTAMINATION;
(date) (signatu e)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is
granted under 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.
2.
3.
Date of
Pump the well until the water is clear.
Disinfect the well in accordance with th-e requirements
of the Putnam County Health Department attached to this
permit.
Submit a Well Completion Report ch a form provided by
the Putnam County Health Depar nt.
Issue: 1 ��_19-P. .
--�_
Permit Ii g f icial
s . Non - Transferrable • . .
AUUHLss.
IUWNIVILLAOt /1.11T 1AX GRiU NUMER.
WELL LOCATION
T
WELL OY`JNER
NAME. •
ADDRESS:
„P,,,T Cyr ,' /�Taa ljo/c 3 77
❑ PSI.V%TL
❑ PUBLIC
USE OF WELL
d REST ENTIAL
❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP
❑ ABANDONED
1 - primary
C1 BUSINESS
❑ FARM 0 TEST /OBSERVATION
❑ OTHER (specify)
2 - secondary
❑ jNOUSTRIAL
❑ INSTITUTIONAL ❑ STANO -BY
❑
MOUNT OF USE
YIELD SOUGHT
—,3-74 gpm. /N0. PEOPLE SERVED __4Z_1 EST.
OF DAILY USAGE • C` gal
REASON FOR
IdNEW SUPPLY
❑ PROVIDE ADDITIONAL SUPPLY
❑ TEST /OBSERVATION
ORILLING
❑ gEPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
WELL TYPE
V DRILLED
F_� DRIVEN DUG GRAVEL Ej OTHER
IS WELL SITE SUBJECT TO FLOODING? — YES _ NO
IF .WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
�srq Tc° LOT NO-: / I
WATER WELL CONTRACTOR: Name Fg /ca,v Ll/e / /Se /vim Address: /°D,
wAOOiNCers • FgJU
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: w YES NO •'
NAME OF PUBLIC•WATER SUPPLY: - TOWN /V /C
DISTANCE TO PROPERTY FROM NEAREST WATER•.MAIN 1 ,
..LOCATION SKETCH & SOURCES OF CONTAMINATION;
(date) (signatu e)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is
granted under 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.
2.
3.
Date of
Pump the well until the water is clear.
Disinfect the well in accordance with th-e requirements
of the Putnam County Health Department attached to this
permit.
Submit a Well Completion Report ch a form provided by
the Putnam County Health Depar nt.
Issue: 1 ��_19-P. .
--�_
Permit Ii g f icial
s . Non - Transferrable • . .
DEPARTMENT OF HEALTH
Division Of Environmental HQ�jLh Services
TWO COUNTY CENTER - CARMEL, N.Y.. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
IS WELL SITE SUBJECT TO FLOODING? — YES _ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
,e5 r,4 re LOT NO.:
WATER WELL CONTRACTOR: Name F41cew �Ve/l Service Address: /' 0, l rS 17
wAoi,vzierr F9'l& ,_ -_ moll, S/. 4,75 -�16
V
IS PUBLIC MATER SUPPLY AVAILABLE TO SITE: _ YES V1 NO -
NAME OF PUBLIC -WATER SUPPLY: - TOW1T/V /C
DISTANCE TO PROPERTY FROM NEAREST WATER•.MAIN ,
..LOCATION SKETCH & SOURCES OF CONTAMINATION,
(date) i (signatu e)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is
granted under 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 ch a form provided by
the Putnam County Health Depar nt. 4\
Date . of Issue: (� 19
Permit Issui g f icial
Permit.•is .Non- Transferrable
p 5
IUWNIVILLAGE /C11Y IAX UAW NUMbEA.
WELL LOCATION
T /6 y
,47TeP�Sv� TAXri�
/S'•- �/ as.
WELL OWNER
NAME..
10641JN XAm
ADDRESS;
,; edW nP -1T CQr ,' /'Taa 0117a- ax 3712
❑ PSIVITE
0 Euak
USE OF WELL
Q REST ENTIAL
❑ PUBLIC SUPPLYv ❑ AIR /COND. /HEAT PUMP
❑ ABANDdNED
1 - primary
❑ BUSINESS
❑ FARM ❑ TEST /OBSERVATION
❑ OTHER (specify)
2 -secondary
❑ INDUSTRIAL
❑ INSTITUTIONAL ❑ STAND-BY
❑
AMOUNT OF-USE
YIELD SOUGHT
f gpm. /N0. PEOPLE SERVED __4Z_1 EST.
OF DAILY USAGE gal.
REASON FOR
NEW SUPPLY
O PROVIDE ADDITIONAL SUPPLY
❑ TEST /OBSERVATION
GRILLING
❑ aEPLACE EXISTING
SUPPLY ❑ DEEPEN EXISTING WELL
dDRILLED
F__j DRIVEN DUG GRAVEL E] OTHER
WELL TYPE I
IS WELL SITE SUBJECT TO FLOODING? — YES _ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
,e5 r,4 re LOT NO.:
WATER WELL CONTRACTOR: Name F41cew �Ve/l Service Address: /' 0, l rS 17
wAoi,vzierr F9'l& ,_ -_ moll, S/. 4,75 -�16
V
IS PUBLIC MATER SUPPLY AVAILABLE TO SITE: _ YES V1 NO -
NAME OF PUBLIC -WATER SUPPLY: - TOW1T/V /C
DISTANCE TO PROPERTY FROM NEAREST WATER•.MAIN ,
..LOCATION SKETCH & SOURCES OF CONTAMINATION,
(date) i (signatu e)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is
granted under 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 ch a form provided by
the Putnam County Health Depar nt. 4\
Date . of Issue: (� 19
Permit Issui g f icial
Permit.•is .Non- Transferrable
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HOUSE AND VJELK- LOCATIONS AS \�
f22 SUKY'rry K2. H. �Et�c NDOIeFF 88.
VA7eD NOv. ►O, 1957
rutnam iounty Uapartm t Of ea1tL
A nvleion of Ervironrnsnt Hoalt 3ervieec
o
0
(3� p(Qpp approved as noted Po- conYo a with
ipplioablo Mules a geg, atiO Of the
00 HOUSE putt County He th Departm
000 &AL- :tamet rp
LOT 11 k: ! MA50n1R -f
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KTE 1104
-TOWW OF PATT ERSON
FUTNAM CO., N.Y.
B-f
T. MICHAEL DAL--(,t-,e.