HomeMy WebLinkAbout1020DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.47 -1 -71
BOX 10
�L _
6 Lim
I I 4m t , :1
L , ,
�'V '�
�. L Li �
f iz '� �. . 16 7�r
01020
04/12/2011 15:39
8452258420
BDVDARTESIANWELLC
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL. HEALTH SERVICES
WELL COMPLETION REPORT
PAGE 03105
Well Location
Street Address:
Town/Viltage:
Tax Map # ;'/ _ J
Ma� Block Lot(t)
Well Owner:
Name: Ad ress:
Use of Well:
1 -Primary
2- Seconds
,,Y,ResIdentIaI _Public Supply ,,_Air cond /heat p mp _,Irrigation
Business �Parm Test/monitoring —Other(specify)
Industrial Institutional Standby
Drilling Equt mant
Rotary Cable ercussion Compressed air percussion Other(specify)
Well Tye
_Screened Open and casing X Open hole in bedrock _Other
Casing Details
Total Length -ft.
Length below gra&40t.
Diameter _(g_in.
Weight par foot / Ib /ft
Materlals, Steel plastic Other
Joints: Welded X Threaded Other
Seal: 2.cCement grout Bentonite Other
Drive shoe: Yes No
Liner, Yes,2�,_No
Screen Details
Diameter in
Slot Size
Len th ft )
Dept to Screen ft
Deveio ed?
First
_Yes _No
Hours
Second
Well Yield Test
_Bailed _Pumped 2C Compressed Air
Hours
Yield gpm
Depth Date
ea6uro it an su ao- static ISheC ty
ur ng yield tort 1ft) opt d compete we n t.
d
Well Diameter
in Formation Description
Well Log
If more detailed
rnfomlation
descriptions or
sieve analyses
are available,
please attach.
Depth From Surface
Water Bearing,
ft: -
ft.
Land Surtaco
r
AMA
'
If yield was tested
at different depths
during drilling
list:
Feet
Gallons Per Minute
Pump/Storage Tank information
ILOD
v
Pump Type _ Capacity_
Depth Model
Voltage HP
Tank Type Volume
4
[�[Iil,'
F,. h
� �f�3f�t�'
�
�I'�7� at33i;ilfl:'i?�i`
.I„ +. t . '�
„ I
tits. °��'�,�fil,°��1;.��.�41Ctii��44
^l' ��, .,�h! ct
• , . �, �
ra
�!�[
�'
��ta
� , „�
•`�'•.
�
f,.;
u�;�
be
provided
l ,t
t .
on a separate sheet/olan.
•;t' , M '';all:,
h1F �� � �� al�;!
", m!lr+ ...
l,`rR yl
MrITIM.
=V!br,+ I
.,, -�Hnn
of wall
with rtictancpt
to at 1paSt
two
permanent
landmarks
to
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
Rev. 3106
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
El
please print or type C� t'e = a»,
Well Location .
Street Address: Town/Village:
Tax Map # '/
J
��,
Map Block Lot(s)
Well Owner:
Name: Address:
Phan #:
Use of Well:
_IX—Residential _Public Supp ly,
Air /cond eat pump _Irrigation
1- Primary
Business Farm
Test/monitoring _Other(specify)
2- Secondary
Industrial Institutional
Standby
Amount of Use
Yield Sought gpm # People Served
Est. of Daily usage gal.
Replace Existing Supply Test/Observation Additional Supply
Reason for Drillin
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
Z J2 or
for Drilling
Well T e
Drilled Driven Gravel
Other
Is well site subject to flooding? ....................................................... ............................... Yes _ No-X-1
Is well located in a realty subdivision? ............................................ ............................... Yes _ No_z
Name of subdivision
Lot No.
Water Well Contractor: '
Address: � � 7
Is Public Water Supply available on site? ....................................... ...............................
Yes No
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed w II location & sources of contamination to be provided on separate sheet/plan.
Date:- Applicant Signature: J�V.Ole
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Departmel
take appropriate action to assure that any and all water and 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.
®re.
APPROVED FOR CONSTRUCTION: This approval expires4we year from the date issued unless construction of the
well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified
when considered necessary by the Commissioner of Health. Any revision or alterat' n of the a prove plan requires a
new permit. Well to be c nstructed by a water well driller certified by Putnam Court
Date of Issue �o Permit Issuing Official•
Date-of Expiration ll Title: (, ItiLrlf
Permit is Non- Transferable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -g7
Rev. 3/06
�TS�A�F
CA
d�
J01,14
,3 -,�
_
A F E
S4
_E�
7 f .
7�\ r �•
,
3
d�
J01,14
SITE LOCATION
OWNER'S NAME
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
MAILING ADDRESS Zam x
OFFICIAL USE ONLY
if16Or o
'Son. TM#
p PHONE a'i 1 S 116 (0
PERSON INTERVIEWED da I e-0,17 v PCHD Complaint #,
ame Relationship (i.e., owner, tenant, etc.
DATE 1-05--o
TYPE FACILITY
PROPOSED INSTALLER � c c- PHONE 7 YG S-
ADDRESS -�O • Z®x S,q,)- N L .REGISTRATION#
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submittal. of proposal from licensed professional engineer or registered architect.
Tt
_I,,.as.o_ym'- er,or re agent.of..o.ymer_agree to.the conditions stated on- this.forin.... - -..
SIGNATURE Ariz,% TITLE _ DATE —5--0 . I
Proposal approved with the following_ conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6 diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
G
//DATE"*"
60
r% e
To
AN3
AINnO.")
4