Loading...
HomeMy WebLinkAbout0784DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -1 -93 BOX 9 ,Iry mall in I I 16 0 rp mr ILL � ,y ,1 oil I .; I In 6 UL �T,.-�,,, -, r * •s?.+IC•.�m;�•.'rrp";s. ^aR -.,: _ 7. P,DINAM COIINTY DIM" )"1' n n i A CO ^ "a WELL GUM- eLETIUDI mirucct DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH 0 Office Use Only WELL LOCATION STREET ADDRESS WNI t TAX GRID NUMBER: e c� WELL OWNER NAME: AOORESS: QJ e go M PRIVATE p PUBLIC USE OF WELL 1- primary 2 - secondary [RESIDENTIAL PUBLIC PPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED O BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) O INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT _45— gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE O!5'00. gal. REASON FOR DRILLING .[] PLACE EXISTING SUPPLY ❑TEST /OBSERVATION []ADDITIONAL SUPPLY rAINEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA. WELL DEPTH ft. I STATIC WATER LEVEL ft. DATE MEASURED DRILLING EQUIPMENT O ROTARY COMPRESSED AIR PERCUSSION ❑ DUG O WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH _ L_ ft. MATERIALS: IfSTEEL R PLASTIC 0 OTHER LENGTH BELOW GRADE ft. JOINTS: ❑ WELDED ffTHREADED O OTHER _ DIAMETER in. SEAL: ❑ CEMENT GROUT O BENTONITE OTHER Ic WEIGHT PER FOOT /. Ib. /it. DRIVE SHOE. ❑ NO LINEA:OYES 0 SCREEN DETAILS ETER. in SLOT SIZE LENGTH (It) DEPTH TO SCREEN (ft) 0 PED? FIRST O YES ONO HOURS SECOND - -- - _ __ .....- .. -_ -••- __. GRAVEL PACK O YES ❑ NO GRAVEL METER OF PACK in. TOP DEPTH 1t- BoTToM ft. WELL. YIELD TEST If detailed pumping 4QH00: O PUMPED i tests were done is in- COMPRESSED AIR ,formation attached? O BAILED ❑ OTHER ❑ YES ❑ NO 'WELL LOG If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- ing well D'a- Meter FORMATION DESCRIPTION WOE It ft_ WELL DEPTH ft. DURATION hr, min. DRAWOOWN YIELD 9Cm• Surface eft. WATER 9CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? O YES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY GAS,. PUMP INFORMATION TYPE MAKER MODEL CAPACITY DEPTH VOLTAGE HP WELL DRILLER NAME DATE AD O ERT M. HYATT & SONS'SIG�NJAT. Well frilling ,. Rte. 911 R. R. 2 Box 171A n, t 9 ;. NORTH AMERICAN LABORATORIES, INC. ANALYSIS DATA SHEET TYPE: PW LOCATION: Lot 10, Courtney Lane, Patterson NY REPORT TO: Ross Alan ADDRESS: 25 Byram Lake Rd CITY, STATE, ZIP:Armonk NY 10504 DATE COLLECTED: 01 -06 -95 TIME COLLECTED: 11:30 AM COLLECTED BY: R'. Alan REPORT DATE: 01- 07 -95' LAB # 95 -0060 SAMPLE SOURCE: Tank DATE ANALYSIS RESULT UNITS METHOD ANALYZED- Total Coliform Absent COLILERT 01 -06 -95 THIS SAMPLE AS RECEIVED AT THIS LABORATORY DID MEET THE REQUIREMENTS OF NEW YORK STATE DRINKING WATER STANDARDS. • Laboratory Director NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218 618 Clock Tower Commons, Rte 22, Brewster, NY 10509 / 914.278 -7600 / Fax 914 - 297 -0536 p -� -�� PUTNAM COUN1Y DEPARTMENvr OF HEALTH DIVISION OF ENVIRONLKaTIAL HEALTH SERVICES Own or Purchaser o£ Building v .A Building Constructed by Location - Street: MuniciF lity f Building Type :24, --- I -- � 3 Section Block Lot = 1 Subdi.vi ion Name 16 Subdivision Lot s GUARARTEE OF SUBSURFACE SEROR DISPOSAL SXSM 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 st cwn 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 armer, 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 immediately following -the date of approval of the "Certificate of Construction_ Compliance" for the sewage disposal system, or any repairs made by. rra to such system, except where the failure to operate properly is caused by the willful or negligent act of the cccupant.of the building utilizing the system. - 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 occupant of : the building util iz ing the system. Dated this clay of 19� �os5 A1a�. n� Generak Con-ti-actor (0wner) - Signature Corporation Names (if Corp.) Address Al- \11 rev. 9/8s Mk Signature Title Corporation Name (if Corp.) P ess CP¢ �.Yl i =. ;=r z�rcL z' =-� C- bG� 0Ce — eEu.� I C Ccr TC� J L.' =r Gi. ="' = IO == C :: /Ze - - ; � �_ _ ; _ _ ____ ___ �c cam_ ► , I CZ Z_ J E:-= -= _ci-sr cf c= -: is t ==-c-± L" Z LCE= .. 1 s_zis c= t_ — =� I { 2. I:c:_ I { w_- -___= he F --= `h L=ta _ _t I I -_ - �_ - -- -. - -_� _:�- ?ce_— c� a rcv..... �Z_ t= c= _Z:V D! Inc { { I C_ �_ c.c �_- =-= c= C:_'_- ham'• -! - _� C'-v = =� C. 1_i �i `_c f_r•c-, W: `"1 l,�_C; CL _;- ;�, 1, C. :L1ct2r:c G.=_ - C..�_c -�� c�rct/ t -�-�` c_.- I I ca wat sww�s TRW t� Arai Fm sectbe ovy Vobsod Nadler �[ Des4altow G 'P 'D �C® NoU0eaflia 41te44hed When FIU V ti pM�ed y�, Si�de�ia .. S7W . li ewit bE GaBw siot 1L�. taai - -�' �F� ... To M tier4tatied d� 'f :i C7 Afllta W tiblt Ptirc Std ptao• Adleia , y, .peed by':7 OtMr 1 represenCthtt I am wholly and „completely nspons�ble for design and lo(at;Ori of ,.the Proposed systam(sl; 1) that the ssPtraiS nwa i di' oral t stem _ .: l above described Will be'eonstructed as drown owtbe app!�ed amendment then twang in accordi`nco With tM'stanAirds, rulei in8 regu cans Or .ter wsnam County DePawtment -of NtNth, and that on C''i�- "",.!htreof r',-Coriificit� of'Consductbe :ComoNancW Ytidactory t0 ter Commialoeer of FlwltbwlN be submitted. to'the Oep rtnMit..and.'a written Warantee, will be furnished the owner, his sucoanors; heirs or assips by thsi•bi+Nder. that fled builder will Olace in food operating ;condition .any 'Part_ of. •said: sinvao disposil syste durirp'tha, p@riod of two (t► W iMdletely ,#ollowins'thadate -of the issu- ana of. ter ;Aoprowl of tfw •t;ertNkats- of "Construdia+. Compliaeiee'of: the orginal systeni; a any rigirs t 0; 2) t t t e drilled wet detal0ed above sWN M Wetted as showtt;on.tM appoved'plen �nA`tMYNkly well wilhM Inst in',accordanos'” , h sta wla rule a pu IEFS Of: the' Putnam county Department of ►/Nlth: Date /� SigneA P.E. v R.A. Add► T APPROVED FOR CONSTRUCTION; This i revocable for.cau» I or Milo :b :aminded or requires a new :permit. Approved for elii �v. z 10/88 .I. .c:.a 1 r: -.N pr ',al pNK,two yeah' from the date i unki;s 'c, st►uctlen O ter building to. been undertaken and if odif6l When ConfidNbd"nemsry by the COmmisfionar ,Of 'MYlt.. Any change or alteration of construction b�sst�l'76�f�domtstk sanibry stvira4s; and /or prhra iter Puppy only. c :j7 9y Title DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva.Road, Brewster, New .York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL Q 9 PCHD PERMIT WELL LOCATION Street Address Town Village City Tax Grid Number Sri' 2 WELL OWNER Name Mailing Address ALAO D, p WPr vate O Public USE OF WELL 0 - primary 2- secondary ta RESIDENTIAL O PUBLIC SUPPLY 0 BUSINESS O FARM 0 INDUSTRIAL O INSTITUTIONAL O AIR /COND /HEAT PUMP 0 TEST /OBSERVATION O STAND -BY 0 ABANDONED U OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal 0 REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 13. ADDITIONAL SUPPLY 19 NEW SUPPLY NEW DWELLING O DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE ®DRILLED DRIVEN []DUG GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES r/ NO 'IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. 1/7 WATER WELL CONTRACTOR: Name "r..%�. 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 6 SOURCES OF CONTAMINATION PROVIDE ON SEPARATE SHEET 2 CLjvt" (date) s gnature 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 thirt -y (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. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: 19 -7 Date of Expiration 19 ,7� Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re : Property. of A1:�Ltl ...Located at—. GD'U S`� I/AWle� (T) Section ',�7-4. Block I Lot A�. Subdivision of V1(4 �L Ld Subdv. Lot # j). Filed-Map # A Date Gentlemen: This letter is to authorize a duly licensed pro_fess-i.onal engineer tl or-registered architect (Indicate) to apply for a..Constrttction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or.r.egulat.ions as promulagated by .th.e.Commis'sioner of the Putnam County. Department of Health, 'and-; to sign all necessary papers on my behalf in connection with this matter and to supervise-the construction of said system or systems in conformity with the provisions' of Article 145 or 147,"Education Law:, the - Public Health Law, and the Putnam County Sani- tary Code..... Coun P:E. , 4*4 , Very truly.yours,: Signed Owner of Property Address *w4 L�� 4J Y: 1 o�oq Telephone 9�5`��i�cM Address Town Telephone iC7TNA.M CO�C?N7"SZ" i>EP,P;.RTM>EN'I'.. OF HEALTH r APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name- and Address of Applicant: 9222 ALA 1 2. Name of Project:. 1�ILU(�D�J�t� GJ�bry 3:.' � LocationOv/c: 4. Project Engineer: _�� `� W . k11 GND�r�- =7T? S: ::Address:-. License Number: Phone : 11 � Glob 6. Type of ..Pro ect: ; - ... Private /Residential Food. Service`: Commercial' Apartments Institutional Hobile Home Park Office Building; Realty..;SubdivisJon Others (specify) rx 7. Is this project subject`to. State.. Env ironmental •Quality• Review .(SEQR)? l T.ype'Status (Check One) Type I.•. Exempt Type .II. Unlisted. ; 8 Is. a Draft EnVYronmental Impact Statement_ (DEIS) required ?.., 1JU 9 Nas DEIS''been completed •and .found accepta6ley Lead Agency ?: ... n A , 10' Name,.of Lead Agency _ ,.,. /Q 11. Is this project In. an. area under the: control of -local, planning; zoning, or other officials, ordi'nanc'es ?.... ; ....... . • • • • • • , , • • , • • 12. If*so, have plans been submitted to such, author .flies ?..... __ . .....� .......... . 13. Has-preliminary a pproval been 'granted b y such authorities o._ rJ /Q - Data Granted: . 14. Type of Sewage Dtsposa-T.. System* Discharge....... :Surface Water. v Ground Waters 15. If surface water discharge, what is the stream class designation ?........ _ tTlA :6. Waters index number (surface) ...............: ............. :7. Is project located near .a public .water supply system? N G 8: If yes, name of water supply /A Distance. tJwater supply , 4. Is p. project site near a public sewage collection or" d.is o' sal system? ..... Igo .0. Name'bf sewage system Q%A LL Distan ce to sewage a e system Oate otis'erved: 23. Name of Health Inspector: N1 f OLAr- 106r—1 4= Project design'flow (gallons per day).. ............. ............... boo 2. 25.. Is State Pollutant Discharge Elimination'System (SPbES) Permit required? 26. Has SPDES Application been submitted to local DEC Office? 27. Is any portion of this project located within a designated Town or State wetland ?... ........ ............ ... r.l[) .28. Wetland ID Number ............ ................. ........... : . . . 29'. Is. Wetland. Permit required ?.: >_ Has ' appl ication been made to :Town or Local DEC Office ?. 30. Does project...require,a.DEC Stream. Disturbance Permit? fJ0 . 31. Is or was project site used, for agricultural activity,involv.ing application .:.. of pesticide$ to orchards or other crops, solid or hazardous waste .disposal':' landfi l ling, *sludge applAcat.ion or industrial activity? ....... r:`.YES or N0- r,)v 32. Is.project located-within 1;000,feet :of- existence of abandoned landfill, hazardous waste site, salt stockpile, .lAndfill,.sludge. disposal site or . any other potential :known•source of •'contamination ?..:: :'... ::YES or• NO IJQ DESCRIBE• -. 33 Is there a local master plan or file:xith'the Town'or Yi1lage7 ....... .$ h'' 34. Are.,.community_ water, severer facilities, . planned to be developed..within.15.`years ?.* VNiNA00, 35. Are any- sewage.disposal' areas_ in excess of•:15ro slope? ... .......... 36. Tax Hap ID Number .......................................................... 37. Approved Plans are to­be; returned,to:; ..... :........... Applicant _� Engineer If the application is signed.by a`person other than the applicant: shown in Item.1, the. application must be-.accompanied by-a. Letter of Authorization:-' Failure -to comply with this. . .orovision maybe grounds for the rejection of any submission. I hereby affirnm, under- penalty of perjury,-- that in format iont'provided on 'this' fore is true to the best of my knowledge and belief. False statements made herein; are punishable as a. Class A..Nisderreanor pursuant to Section 210.45 of the Pena T Lair. SIGNATURES OFFICIAL TITLES: ' AILING "ADDRESS: ►.1.q .... ... .. u. r� � �nl i - Lrrhturir,.�vl' Ur' ritAL'lH *:­, DZtT2 ; OF DESIGN.: DATA SHEET- SUBSUFACE S&gAGE DISPOSAL SYSTEM FILE .ND. : ' Owner Located at (Street)_ /11 ti IzT��`i 1��:.1; ' .. � ' ..; :. _ .. sec. Block .. '. , Lot 'I •.. (i.nd_t nearest- dross., street) _ __ _.:._.._... _ :.._.... _._._ municipality: cipality Watershed.:. . G�0 SOIL PERCOLA CN TEST DATA RDQUIRM.TO °BE SUBMITTED -WITH APPLICATICNS..• Date of--Pre-Soaking " - 8 0 / g r Date of Percolation" Test "8 a / $ HOLE- .. _ .. ,..... _.... _ __ , ..... NUMBER ' CLOC F, TIME PERCOLATION PERCOLATION Run. _... _. • - Elapse Depth to Water F7rcm Water Level - No. Time ..Ground Surface. In • Inches . ':' . .Soil Rate. Start -Stop --Min*.,, ......start __ - ....Stop Drop 1. In .Min /Iii Drop Inches ~ Inches Inches, 4 rev. 9/85 2-/2:/0' -�2:�0 ;�� 2¢'' 2 .7'' 31' _ .... ........... . ... .... _ .. ......... . .. _ ,.... _.__ ._......._.._ .. _..._. 4 . r. 'S: .. 4 rev. 9/85 3' 4' 5, 6' HOLE NO. Name{, i'Lf4Y t�J �I I GNULG� it !Z. Signature fv, - -x j D Ic.I' I N- Cam' SEAL -i ,Address ;�� >;;�,� _ T ILA fJWN P• Ne,561e4 e'er �/v S 6 r THIS` -SPACE FOR USE BY HEALTH DEPARTMENT ONLY Soil Rate Approved sq. f t %gal.. Checked by.: :Date ' — Y LANE R =50- 00 Z =,?.f 00 .45- SU//-;r ENS /ON cH,4 R 7- I"IIVrr) A 41 0 20.5 75.5 7-9.5 83.0 680. 93.0 50.5 50's 58.0 64.0 72.0 47.5 54.0 59.9 65.5 71.5 54.0 65.0 730 800 a I I pt1s r. Ivry I N. I $I -`i .45- BU /L T DIMENS ION CHART,11N rr.1 N° A 8 1. 41.0 ?0.5 2 75.5 47.5 3 79.5 54.0 4 � 63.0 59.5 5 880 65.5 6 93.0 71.5 7 50.5 54.0 8 52.5 65.0 9 58.0 73.0 10 64.0. 600 ll 7? 0 60.0 12 100.0. ....Coo /3 106.0 680 14 116.0 76.0 15 109.0 73.0 16 NO 79.0 l7 99.5 780 /6 79.0 65.0 l9 116.0 64.5 'V7? Ess [oT9 TH15 IS TO CI✓12TIFY THAT THE SEWAGE DISPOSAL SYSTEM WA5 CONSTRUCTED AS INDICATED ON THIS FLAN AND THAT THE SYSTEM WAS INSPECTED f3Y ME BE FORE IT WAS cavr-KED OVER, THE 5Y5T E M WAS CON STIZUCTE O IN. ACCOK DA NOE WITH ALL STANDARD IKULES AMC) REGULATIONS OF THE PUTNAM COUNTY DEPAIKTMENT *OF HEALTH AND TI-+E NEW YORK STATE DEFWF- T'MENT OF HEALTH . a, w Ess [oT9 TH15 IS TO CI✓12TIFY THAT THE SEWAGE DISPOSAL SYSTEM WA5 CONSTRUCTED AS INDICATED ON THIS FLAN AND THAT THE SYSTEM WAS INSPECTED f3Y ME BE FORE IT WAS cavr-KED OVER, THE 5Y5T E M WAS CON STIZUCTE O IN. ACCOK DA NOE WITH ALL STANDARD IKULES AMC) REGULATIONS OF THE PUTNAM COUNTY DEPAIKTMENT *OF HEALTH AND TI-+E NEW YORK STATE DEFWF- T'MENT OF HEALTH .