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^ "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
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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 .