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BOX 11
01041
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PUTNAM COUNTY DEPARTMENT OF HEALTH /
DMSION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
_ please printorty pe PCHD Permit # �•(l (/ -- -_�
Well Location:
Street Address: Town/Village Tax Grid #
10 Cornwall R.d o, Patterson, NY Map aS 5/$ Block 1 Lot(s) 3 y
Well Owner:
Name:
Address:
Thomas Colabatistto
10 Cornwall Rd,, Patterson, NY
Use of Well:
xxx Residential Public Supply Air /Cond/Heat Pump Irrigation
1-primary.
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought 5 gpm # People Served 4 Est. of Daily Usage ___gal.
Reason for
xxx Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling)- Deepen Existing Well
Detailed Reason
100 ft. well dry. D.r.i11 new we within to 10 feet an
no closer to SOS.
for Drilling
Well Type
xxx Drilled Driven Gravel Other
Is well site subject to flooding? .............:................................... ............................... Yes No XX
Is. well located in a realty subdivision? ...................................... ............................... Yes No xx
Name of subdivision Lot No.
Water Well Contractor: MILL DRILLING, INC. Address: PUTNAM AVENUE, BREWSTER, NY 10509
Is Public Water Supply available to site? .................................. ............................... Yes No xxx
Name of Public Water Supply: n! a Town/Village
Distance to property from nearest water main: :n /a
Proposed well location & sources of contamination to be ro ' ed on se arate sheet/plan.
Date: 1.0/ 14/ 97 Applicant Signature: -
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 Department. During all well drilling operations, the applicant and/or
well driller shall 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.
APPROVED.FOR CONSTRUCTION: This.approval expires two years 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 Public Health Director. Any revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water well driller certified by', Putnam
County.
Date of Issue • .� 2 Q � Permit I s ci : 1
i�_ I�g � � 1
Date of Expiration 1,,0 1 2Z] ff f S Title:
Permit is Non- Transferrkble
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
s
APPENDIX E
FORMAT CONSTRUCTION PERMIT
NEIGHBOR NOTIFICATION LETTER
Date
25
RE: Department of Health Review of Proposed
Sewage'Treatment System for Property
Name: C, 0 �p,L�,4.1 -r
Address: 10 �A
Town: ir��so,,�� Jay-
Tax Map #: Z.�, y g- (°-
Dear .
Please be advised that an application for a Construction Permit relative to the construction
of a- well proposed for the captioned property has been made to the
Putnam County Department of Health. Attached please find a copy of the latest site plan.
If. you -have any questions, - conddrns or 'inforrnaiion which may bear on the Health.
Department's review of this application, you may call the Health Department at 278 -6130.
Very truly yours,
Title:
r
Received By:
Address: S 1401L �? . � 3 �_ aw P_ GKCE Q (L � v E � �� TT�►'S o� r�l
. y
Tax Map #: c2S, ale 38 C37
August 1997
25
APPENDIX E
FORMAT CONSTRUCTION PERMIT
NEIGHBOR NOTIFICATION LETTER
Date
RE: Department of Health Review of Proposed
SewageTreatment System for Property
Name: c- LON-0 -ATII- ry
Address: io C oRttwa-c D
Town: 'P,wru -f p-so),
Tax Map #: Z5. '-18-(
Dear
Please be advised that an application for a Construction Permit relative to the construction
of a s for well proposed for the captioned property has been made to the
Putnam County Department of Health: Attached please find a copy of the latest site plan:
If -you have any questions, concerns or information which may bear on the Health
Department's review of this application, you may call the Health Department at 278 -6130.
Very truly yours,
Title:
Received By: /`,':'- -
Address: 6 cec&,- Die. UOpuz U- ZGM
Tax Map
August 1997
25
APPENDIX E
FORMAT CONSTRUCTION PERMIT
NEIGHBOR NOTIFICATION LETTER
Date
RE: Department of Health Review of Proposed
SewageTreatment System for Property
TR- lowt�s � ►�tcN��� ,
Name: C #6.��.-T
Address: lo C.oz4,,Atc Zb
Town: ' ? ^- f-r-f.e.sot1, tiiy.
Tax Map #: aS. y8
Dear
Please be advised that an application for a Construction Permit relative to the construction
of a. or well proposed for the captioned property has been made to the
Putnam County Department of Health. Attached please find a copy of the latest site plan.
• - If- you- have 'any-questions, concems or :information which -may- bear on the Health
'Department's review of this application, you may call the Health Department at 278 -6130.
Received By:
Address: 33Z LA'^' �-
Tax Map #:
Very truly yours,
B YyCYj
cnw �
Title:
August 1997
f
1
25
APPENDIX. E
FORMAT CONSTRUCTION PERMIT
NEIGHBOR NOTIFICATION LETTER
Date
- z
RE: Department of Health Review of Proposed
SewageTreatment System for Property
Name: s7q
Address: 10 Coe aikYkc1- '?Z-
Town: IJ
Tax Map #: 1
Dear
Please be advised that an application for a Construction Permit relative to the construction
of a sewage-4,ystemQaWor well proposed for the captioned property has been made to the
Putnam County Department of Health. Attached please find a copy of the latest site plan.
' 'If, you'hdve -Rdy -...questions" concerns or information which may bear on the Health
Department's review of this application, you may call the Health Department at 278 -6130.
Received By: 01- n
Address: 7 (f02AWA-I,(-'
Tax Map #: �J� —34-
Very truly yours,'
Title: �rz�
August 1997
i
1
_ - 25
APPENDIX E
FORMAT CONSTRUCTION PERMIT
NEIGHBOR NOTIFICATION LETTER
Date
RE: Department of Health Review of Proposed
SewageTreatment System for Property
..iNO� �`� � ►tilir_Hf t�
Name:
Address: i o Co oviA.L -
Town: �P^nTE zso�t) AY
Tax Map. #: 95-. 4$- ! 3
Dear
Please be advised that an application for a Construction Permit relative to the construction
of a. se _ d/or well proposed for the captioned property has been made to the
Putnam. ounty Department of Health. Attached please find a copy of the latest site plan.
If ou have �an ue`stibns- concerns �`or information which may bear on � � w
- . .. ... � y q y the Health
Department's review of this application, you may call the Health Department at 278 -6130.
Very truly yours,
rj
Title: -�!
Received
Address:
Tax Map #: 2 ,5- `I g / —440
August 1997
25
APPENDIX E
FORMAT CONSTRUCTION PERMIT
NEIGHBOR NOTIFICATION LETTER
Date
RE: Department of Health Review of Proposed
SewageTreatment System for Property
'rUOMA-'S 4� N1cN9'Z9
Name: GJaLA�3A7-1 -
Address:
Town:�Trfsn��
Tax Map #: Z 5. r,{o ( _
Dear
Please be advised that an application for a Construction Permit relative to the construction
of a well proposed for the captioned property has been made to the
Putnam County Department of Health. Attached please find a copy of the latest site plan.
"If 'Y`64' have any questions, concerns or information which may bear on the Health
Department's review of this application, you may call the Health Department at 278 -6130.
Received By:
Address:
Tax Map #: a)s Li
—1 — S4
Very truly yours,
August 1997
W,
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4 - PUTNAM COUNTY DEPARTMENT- OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT Permit-W-90-97
' WeItI:oe mn-
', :_..
Street Addre`ss:y _. __. ___.___ ____ .__
10 Cornwal l Road
,town7� page - -
atterson, NY
Tax Grid #
Map Block Lot(s)
Well Owner:
Name: Address:
Thomas Colabatistto, 10 Cornwa`11.11d., Putnam Lk., Patterson, NY
Use of Well:
1- primary
2- secondary
xx Residential Public Supply Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Dolling Equipment
Rotary Cable percussion xx Compressed air percussion Other (specify)
Well Type
Screened _ Open end casing xx Open hole in bedrock _ Other
Casing Details
Total length 41 ft.
Length below grade 4D_ft.
Diameter. 6 in.
Weight per. foot 1 lb/ft.
Materials: xx Steel Plastic _ Other
Joints: _ Welded Threaded . Other
Seal: Xx Cement grout _ Bentonite _ Other
Drive shoe: xX Yes _ No
Liner: Yes _ No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
_ Yes No
Hours
Second . . ,
Well Yield Test
_ Bailed _ Pumped xx Compressed Air
Hours 6
Yield 5 gpm
Depth Data
Measure from an surface- static (specify ft)
65
During yield test(ft)
300
Depth of completed well in feet
365
Well Log
If more detailed
information
descriptions or
sieve analyses
are,availabl6o
pleas eattacl�
—
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land surface
3
TO soi
3
385
Hard granite w/layers of pink qua
If yield -was tejted
at different depths
during'-"m6.'
list:
Feet
Gallons Per Minute
1j.
Pump /Storage Tank Information
Pump Type Capacity
Depth _ST ZVO6Model
Voltage HP
Tank Type Volume
305.
325
.2
.365
5
385
5
ate a mp ete
10/3.1 /97
Putnam County Certification No.
3
Date of Report
1'0/31/97
Well Driller signature
I
1 '1101 Me DAUL 4 MUMUn o1 wett wltn arstances to at Least two permanent lanamartcs to ne provlaea on a separate sneevplan.
M
Well Drillees <RUa rt. 1)41.LL DRILLING, INC. Address: Putnam .Avenue, Brewster, NY
Signature: . Date: 1.0/ 3.1 / 97
White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller
Form WC -97
.z.
NORTHEAST LAB" O*R'ATORY OF DANBURY
b ,
(Formerly. Tarlton. Environmental Laboratory) :
39=3 MILL PLAIN, ROAD - DANBURY, CT 06811
(203) 748 - 7903 -- FAX (203( 748 -0652
{
LABORATOR'
REPORT TO: .
MILL DRILLING, INC.
PUTNAM AVENUE
BREWSTER, N.Y. 10509
CT Cert: PH -0404
NY Cert: 11471
ZgPORT -= WATER SUPPLY TESTING
DATE SAMPLE COLLECTED:
11/14/97
TIME COLLECTED:
1:45 P.M.
COLLECTED BY:
RUSS
DATE RECEIVED @ LAB:
11/14/.97
DATES) TESTED:
11 / 14/9 7 .
TESTED BY:.
LAB #11471
REPORT .DATE:.
• 11/17/97
SAMPLE SITE: COLABATISTTO,10 CORNWALL ROAD, PATTERSON, N.Y.
SAMPLING POINT: - TOP OF WELL
.SOURCE: WELL
TREATMENT: NONE
TEST, PERFORMED. RESULT: RECOMMENDED LIMIT
BACTERIAL:
Total Coliform (Bacteria) , 0 per 1,00 ml 0 per 100 ml
CHEMISTRY:
Chlorine Residual ND mg/L - - - --
ml =milliliter
mg/L = milligrams per Liter
ND = none detected
RESULTS BASED ON SAMPLES SUBMITTED: 11/14/97
SAMPLE; AS TESTED ABOVE: OTABLE or DOT POTABLE
TER,STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
Laboratory Director
•NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230
a
SITE I=TION
1
r
MAILING ADDRESS
PHCNE
TO
%y d7f - 6o&
PERSON INTERVIEWED l (;/Yid 2 POD Complaint # `fa A -8 9
•Name & Relationship (i.e, owner,tenant, etc.)
DATE Aorr, /ye TYPE FACILITY #oiVa _
PROPOSED Ilsm-Lm l v je P NG ,f S M Jrt S- 6 N PHONE Z q
Pro (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 arch'
jtect. ,
3((:5 � S /v:t .r l t•S a9 m,% •_e. y 51A1_-r--.-., c.._fi BSc
GR.
v4 _.
Proposal approved
�t� c
Inspector's
�,04� v U "L/ -� rl �•: sue, d' C / S /n��ra
^
l4-G 27 / J n Q
9O
AO 44 "'1 lam' 1 ,��f -7
Proposal Disapproved
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 corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
.3. System repair to be performed in accordance with the above proposal and conditions.
as owner, or r r er to the above
SIGNATURE TITLE /JZerA4- DATE
MPHS: W'ute (MD); YeUcw (Ttkn ED[); Pink (k i®nt)
m