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Home My WebLink About1219DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.63 -1 -53 BOX 12 I V IN6 'L-' I %1�0, �. r ,r 01219 IN IN r:: NN � ,, T ;� CL� IN 01219 ... _... •, .a+�k. ^'ar N....,.c.; r; =... ;.. ...:a^ .: tC.: «..3�* Kk.'� .n, t•..j ��?°c,N+a�(. z: Cm S tyP ;x.... :^.�. t <EZE20[ %, w TTMT T I1ALdT)T TR+TI%TT DLMI]ADT Wz.LL l,Vi�irLZt.LV" i rKVL" DEPARTMENT OF HEALTH _ .,._, .....__ nip: isien - Of-- ETivironmental. He�altb,_S_ervices . PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only ,_. ,. WELL LOCATION STREET AOURESS: WN I TAX GRIO NUM8ER: _ w A ov �� poi. o� WELL OWNER NAME: ADDRESS: pBSe e r&L 70 M481VATE PUBLIC USE OF WELL 1- primary 2 - secondary PRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O' ABANDONED O BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) O INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING "EW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH , l ft. STATIC WATER LEVEL ft. DATE MEASURED DRILLING EQUIPMENT O ROTARY ❑ COMPRESSED AIR PERCUSSION 0 DUG ❑ WELL POINT SABLE PERCUSSION O OTHER. (specify): WELL TYPE O SCREENED ❑ OPEN END CASING. @OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH _ tL MATERIALS: @{STEEL ❑ PLASTIC O OTHER I LENGTH.BELOW GRADE ft JOINTS:.- 0 WELDED . efHREADED ❑ OTHER DIAMETER ' in. SEAL: EMENT GROUT ❑ BENTONITE OOTHER WEIGHT PER FOOT d lb./ft. DRIVE SHOE S ❑ NO UNER:OYES GM SCREEN DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (f t) DEVELOPED? DETAILS FIRST O YES ONO.. -HOURS StCOND _.... - ....._ ... _�....._ __... _ ...._.. GRAVEL PACK . O YES O NO GRAVEL SIZE DIAMETER OF PACK in." TOP DEPTH —ft. BOTTOM DEPTH It. WELL YIELD TEST ; If detailed pumping METHOD: 11DAMPED 1 tests Were done is in- O COMPRESSED AIR , formation attached? AILED 11 OTHER ; O YES 0 NO WELL LOG. 11 more detailed formation descriptions or sieve analyses . are available, please attach. DEPTH FROM SURFACE wager Well pear- Oia- ing (meter FORMATION DESCRIPTION CODE. ft. ft WELL-DEPTH IL DURATION hr. min. DRAWDOWN It YIELD gFrn• Surrface �L ) 4` DO 0 d 6 a WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED ?. MIES ONO ANALYSIS ATTACHED? fPES ONO STORAGE TANK: TYPE Px,� CAPACITY GAL. WELL DRILLER NAME /(� f' f ��',� �(, a g. 0 I'C:,p DATE ADDRESS J SIGiATURE PUMP IPIFORMATION TYPE 1� S /a9 40-C !ig CAPACITY MAKER DEPTH ___. MODEL - t1OLTAGE21—& HP ELLIS A. TARLTON LABORATORY DIVISION OF ELLIS A. TARLTON, ENGINEERS, INC. CHEMICAL 34 PLEASANT STREET DANBURY, CONN. 06813 -2328 WATER - WASTEWATER PHYSICAL METHODOLOGY BIOLOGICAL P.O. BOX 2328 203 - 748 -7903 APHA - EPA - ASTM i ' 1 - '-:-- -- REPORT- OF,BACTERIOL-OGICAL- AN' D- CMEMICA 'L-.-EXAMINAT40N- OF'- WA-T- ER-- -- - - NAME AND ADDRESS OF PERSON TO RECEIVE REPORT SOURCE OF SAMPLE I Rick's Water Service t I iHickory Hill Road Brookfield, CT,06804 DATE OF COLLECTION DATA COLLECTED BY Water Supply DeFreitas Warren & Lake Port Patterson, NY October 24, 19.88 Rick's Water•Servic t Hydrogen Ion COLOR TURBIDITY ODOR CORROSION INDEX DISSOLVED SOLIDS Concentration LANGELIER ,(pMl 6.5 1 .20 NTU None RYZNAR 191.' Mg/ Alkalinity as CeCO3 Fluoride (F) Nitrite .001 Mg /L Bicarbonate 60.0 Mg /L .00 Mg/ NITROGEN Alkalinity ae CSCO3 Chlorine Residual CONSTITUENTS Nitrate trJ • 8 5 Mp /L Carbonate 0 • Mg /L . 0 0 Mpr AS Total Hardness as C&CO Conductivity NITROGEN (N) Ammonia .010 Mgn � 10 4 . Mg /L 309 Mlcromohos/c Mg /L Iron as Fe • 02 Mg /L Sodium 21.0 Mgr Chlorides as CL 44.0 Mo /L Manganese as Mn .00 Mg /L Mor Detergent as MBAS 0. Mg /L Sulfate as SO4 12.4 Mg /L Mg/ The arithmetic mean of all Standard samples examined per month using the membrane litter technique shall not exceed MEMBRANE FILTER TEST one colony per 100ml. Coliform colonies per standard sample shall not exceed 3 /50MI. 4 /100mi. 7/200m1, or 13 /500ml Coliform Colonies /100ML in:' (a) Two consecutive samples: (b) More than one standard. sample when less than 20 are examined per month; or (c) 0 I. ... _�,..- - _. __.. .. .. More than five par cent of the samples when 20 or more are examined per month. AT THE TIME THE SAMPLE WAS SUBMITTED: 1. The results of the analysis of this sample were satisfactory and met requirements for a potable water. 2. The results of the analysis of this sample were satisfactory for a potable water but certain of the chemical or physical constituents were high. These are as follows: 3. This sample was not satisfactory since it did not meet the bacterial requirements for potable water. The presence of organisms of the colilorm group in a sample of potable water is undersirable and, while not necessarily indicating the presence of any disease producing organisms, does indicate that such contamination might survive to the same extent. The presence of organisms of the colilorm group may also indicate that the treatment was not adequate at the time the sample was collected. ' 4. This Sample was unsatisfactory as a potable water because certain chemical or physical constituents were above acceptable limits. These are as follows: COMMENTS The above parameters meet existing E.P.A. guidelines and Connecticut drinking water standards. Hard water with above average mineralization and acid reaction. Physical appearance js good. Iron and manganese contents are low indicating that brown . metallic staining should not be a problem. The sanitary chemical history shows all nitrogen values within established guidelines. Chlorides are above the area isochlor of 10.0 mg /l and may be due to road salt or softener backwash. Sodium exceeds the 20 mg /l limit at which people on low salt diets should be warned. The rate of corrosion towards iron.-and-copper is•sligh ly above average. Certified e LIMITATION OF GUARANTEE NOTWITHSTANDING the attached statement, it is.intended. that the sole responsibility_'of the Guarantor (septic system installer) is limited to defective workmanship to the extent performed by the. Guarantor (septic- system ins.taller), and to defective materials to the extent supplied,by the Guarantor (septic system installer). In addition, the Guarantor (septic system ;.installer) shall be responsible for the placement of the system' on, the l.ot. in accordance with the plans supplied and approved by the board of health and for building . the system. in accord`ance..w.ith the plans supplied...and.. app roved by the board of health; - However, the Guarantor (septic system installer) assumes no responsibility for the failure of the system to function properly .if..such failure.' is due to the design of the 'system and to the. extent that any materials and /or workmanship.was performed by someone other than Guarantor (septic system installer), or in the event that anyone, after the installation, modified the installation or caused. damage to it in any manner whatsoever° 7 Y7 Building Constructed by Location - Street ` a �J Municipality Building Type Subdivision Name Subdivision Lot # GUARAN= OF SUBSURFACE SMGE DISPOSAL 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 constructed as shown on the approved plan or approved amendment thereto, and in accordance with the' standards i.rules'and -regulations .of the Putnam County Department of Health, and hereby guarantee to the owner, 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 hrmediately following the date of approval of the "Certificate of Construction .Compliance" for 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 occupant 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 utilizing the ^Yste . (SEE ATTACHED "'LIMITATION OF GUARA TEE ") Dated this day of 19 Signatur Title General Contractor lowner) - Signature Corporation Name (if Corp.) Address rev. 9/85 mk ROGER MAYES CONST. CO,;' INC, C6rpora "0A6f Corp-) 0gGHQUAG _N`:Y, 12570 . Address PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY - OFFICE BUILDING, CARMEL, N:_Y. 10512" DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner q4N TN aEmeITAS Address.7 al i31 -1MvS 20 a.ZGWS'iEiL Located at (Street 111TKEP01Z i De-NE Sec. 59 Block Lot I �Indicate nearest cross s ree Municipality Watershed PUTT AM LAKE SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME',t; 2. PERCOLATION'S PERCOLATION No. Start -Stop _apse Time 'Min. Depth to Water From Ground Surface Start.. Stop Inches Inches Water Level in`Inches Drop in Inches. Soil Rate Min. /in drop �..... �. ie5 4., 0'' 12 4 O �-.5 5 1 2. 3 5 PZESOAK Notes: 1) Tests to be repeated at same depth until aroximately equal soil rates are obtained at each percolation test hole. All pp data to be submitted for review. 2) Depth measurements to be made from top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION - -- DESCRIPTION. OF SOTT_`; .r TJCOTTNrfi.F,RED IN. TEST HOLES.. DEPTH HOLE NO. 1 HOLE NO. Z HOLE NO. G.L. - 2 ° 70F>g ll,� STS RooTS 6" SID G VEt, SAND € 012AUSU 12" LAaD wj uAR&& 18" .7 1ZJi E, s �f S 24" 42" 60" 7211 i As �p INDICATE IML. AT. WHICH GROUND -WATT,�ER IS ENCOUNTERED INDICATE 1 v7EL TO. - WHICET WATER L"`TEL °.,,.,ES AFTER BEING ENCOUNTERED TESTS MADE BY T, MiCHM1,._9At,1 , -P�E:: Date AU& i , I gefe . Soil Rate Used(o- -% .Min/1 "Drop: DE =G S.D. Usable. jy P _' No. of Bedrooms Septic Tank Capacity DGU Absorption Area Prodded By ��`j to F. x24" �L X71 Address '�'� THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved. Sq. Ft /Gal. Checked by Date APPENDIX B PUIIMM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SS+AGE DISPOSAL SYSTEMS - -•.... �c REVIEW SHEET PERMIT y DATE �ti .Sa !� rOi✓o�f T� �d /�- ( BY: Location) s ^7 -7— YES No DOCUMENTS Permit Application Corporate Resolution (Name of Owner) (Street COMME IVISAM WO WAM OW-AM LF trench provided �" required �. • 1 • - • contours 100% exp. AM MM y MM es-- 100 yr. flood elev. WOM 11 reservoir, - °C%�� wa_ 150 ft. trigall/galT.___ -�M ��= Plans - Three sets s/s Engineers Authorization Design Data Sheet (DDS) SUBDIVISION Deep Hole Log Perc Consistent Perc Results (3) Fill Perc Hole Depth cd Ho Plans - Two sets elI permit; PWS letter ance Request GENERAL Legal Subdivision Subdivision Approval Checked E�A- approval SSDS Adj. Lots Checked Wetland (Town/DEC Permit R & D) Data On DDS Plans & Permit Same REiQUMM DETAILS ON PLANS Swage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flora Fill Pmfile & Dimensions - Volume D o;Trench /Gallery; Pump pit details Septic Tank - Size, Detail %/ Well Detail, Service Line if over - / ^ Co�str;�^ti�,�i-L3�i:e5.. - igrinaer -rafe)U Design Data: Perc and deep results Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing/Gutter,Curtain Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area; shown; gravity flow, suff . size If Pimped Pit & D Box Shown & Detailed House -No. of Bedroans_� Wells & SSDS's Win 200 ft. of Proposed Systems Property Metes & Bounds House Setback Necessary (Tight lot) House Serer - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees,Top of fill: 20' to Foundation Walls I 100' to Well; 200' in D.L.O.D, 150' Pits 100' to Stream, Watercourse, Lake (inc. expan), 15' to Drains - Curtain, Leader, Footing 35'to catch basin, stor- drain,piPea watercourse' 10' to Water Line (pits -20') 50' intermittent drainage course Septic Tanks 10' fran Foundation; -50' to well 15' Well to PL q DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT #P -�� WELL LOCATION Street Addre s o Town Village City Tax Grid Number WELL OWNER Name 'a1 ;TR Mailing. Wit=" — Address `. GWrivate I] Public USE 'OF WELL 1 - primary 2 - secondary VIIESIDENTIAL E PUBLIC . SUPPLY ❑ AIR /COND /HEAT PUMP ® BUSINESS FARM O TEST /OBSERVATION ®INDUSTRIAL L3INSTITUTIONAL O STAND -BY Q ABANDONED 0 OTHER' (specify AMOUNT OF USE YIELD SOUGHT 5 gpm /# PEOPLE SERVED 10 /EST. OF DAILY USAGE__�gal REASON FOR DRILLING EW SUPPLY , 0 REP ACE EXI TING SUPPLY ❑PROVIDE AADDITIONAL SUPPLY 0 DEEPEN EXISTING WELL; ®TEST /OBSERVATION DETAILED REASON FOR :DRILLING WELL TYPE RILLED ❑DRIVEN 13DUG CIGRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES Cl—'NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: _VuTwA -,-A 1,4K Lot No. L- .WATER WELL CONTRACTOR: Name �' a � Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NAPE OF PUBLIC WATER SUPPLY: TOWN /VIL/CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH.& SOURCES OF.CONTAMINATION O ON REAR OF THIS APPLICATION I,// (date) PROVIDED SEP 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 s.hal l : 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. Date of Issue:/' /s 19 Date of Expiration.: �� 19 �' Permit sluing ic1a Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner 2/87 Orange copy: Well Driller PUn M COUNTY DEPARDOW OF HEALTH - DIVISION OF HEALTH SERVICES SUPPLY & CONSTRUCTION...POWIT- 1,%)X- . '1910 Mame f Owner) SYSTEMS DATE REVIEWED: BY: (Street Location) DOCUMENTS Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole Other d1&ov �}0 House Plans - Two sets If PWS - Letter Variance Request REQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions.- Volume D orJ Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Wel1Detail, Service Line if over Construction Notes - _Design Data Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewage & Expansion Area If'Pmped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Property.Located Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft. 4 110; Type pipe No Bends; Max. Bends 450-w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees 20! to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains- Curtain,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' fran Foundation 50' to Well 15' Well to PL GEIMRAL ,Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data'On DDS Plans & Permit Same John M. Simmons; M.D. _ Denuty- .Commiss.inne.r x ADDRESS DIVISION OF ENVIRONMENTAL`HEALTH"-SERVICES o. . Street. Municipality .(T)(V)(C MAILING ADDRESS P.O. Box Post Office Zip Code TELEPHONE PERSON IN CHARGE OR INTERVIEWED ��G �o�s � �o �,��;1, C, -r / Name and Title DATE TYPE FACILITY �✓ TIME ARRIVED �z7 FINDINGS: r "Ig'. Rout -ine Orig.'-Complain Orig. Request Compliance ` Complaint Comp. Final Group Illness Construction Reinspection Field, Sampling Only Field-Conference _ .O.ther TIME LEFT 2c�, i'' -Z-7 Explain INSPECTOge- -- Signature and itle PERSON IN CHARGE OR INTERVIEWED: I acknowledge receipt of a copy of this Field Activity Report .................. /�.. SIGNATURE: TITLE: TELEPHONE: I John M. Simmons, M.D. PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Deputy Commissioner'�of Health - FIELD.ACTIVITY REPORT - Sheet of INSPECTION NAME t°�l �� Q¢" �/' �ps Orig. Routine ' I Orig. Complain . ADDRESS ,� d'B"i.��ss Orig. Request No. Street Municipality, (T)(V)(C) Compliance' �� Complaint Comp MAILING ADDRESS � � '�'' Final P.O. Box. Post Office Zip Code Group Illness Construction TELEPHONE d' �y id:i�--- Reinspection PERSON IN CHARGE .t Field, Sampling Only OR INTERVIEWED c"S'o'�� ' .� /�'r�. / �%'�vr,'.,,•� .Field Conference Name and Title < _ Other D TES' °° % AViTSYPE FACILITY TIME, ARRIVED TIME LEFT Explain FINDINGS:_. ..... C ✓ re 7rop 01 A00, VW rA3P ,. % �JOc>r . -0' INSPECTOR: d=1 WAR- Signature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge receipt of a copy of this SIGNATURE: Field Activity Report .................. TITLE: o /QC TELEPHONE: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT A) Well-Locution- Stree, Address: - ... .--:---.-:ToWn/VilIa Warren Rd. . 9e: Patterson Tax Grid #- Map 59 Block 7–lLot(s)6-7 Well Owner: Name: Address: .,Def ratis Warren Rd. P'attekson, NY. Use•o'f W611: 1-primary 2-secondary x Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion X' Compressed air percussion _Other (specify) Weil Type -Screened _Open end casing !.X Open hole in bedrock Other Casing Details Total length —ft.: Length below grade —ft. Diameter in. Weight per foot -lb/ft. Materials: Steel Plastic Other Joints: Welded Threaded Other Seal: Cement grout Bentonite Other Drive shoe: Yes No ' ILiner: Yes No Screen Details Diameter (in) Sloit Size Length(ft) Depth to Screen (ft) Developed? First NONE Yes—No Hours Second Will Yield Test Bailed Pumped XCompress6d Air Hours �T_ Yield 5 gpm Depth Data Measure from land surface-static (specify ft), 10. During yield test(ft) 405. Depth of completed well in feet 405 Well Log If more detailed information descriptions or sieve analyses are available, please•a6ch. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. 'Land Surface Deepen existing well 109 4nq GrAnj tP',QliArt7 If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump/Storage Tank Information Pump Type sub Capacity 5 GPM Depth 3 8 0 Model 5GSo7 Voltage 2 3 0 HP _L 3/4 Tank Type 4 2 ST Volume 42 Date Well Completed 2/25/98 Putnam County Certification No. W-8-98 Date of Report 13,/6/98 Well Driller (signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well rille s te Wra_qq Bros Address:162 Baker Rd. Roxbury,Ct. Signature: "P 4 'rd.,-Z;777,f Date: 0 U White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 Number ` APPEARANCE TICKET ISSUED TO: K � ��i�v� r4 ( EFE.7ANT' S NAME) IoS w �Nv''K� tJ DATE �- — t � —C1. -oo \4 (TOWN) (COUNTY) (STA ) YOU ARE HEREBY DIRECTED TO APPEAR IN THE COURT DESCRIBED BELOW ON THE A DAY OF 19 � AT 1 `� IN CONNECTION WITH YOUR ALLEGED COMMISSION OF THE OFFENSE / VIOLATION OFJA,A� � 1 - - -- .CONT, MARY:_ TO..THE...PRQV.ISL,ONS -0E- �FCT.ION.-J..�_`� _' ��;__S.UBD.I -!T . T.....n...tr_ .. _....... -.- . -ISIen OF THE \ �� s �i LOCAL LAW / ORDINANCE OF THE TOWN OF PATTERSON, PUTNAM COUNTY, NEW YORK, AND OR LAW (S) OF THE STATE OF NEW YORK. PATTERSON JUSTICE COURT PATTERSON TOWN HALL ROUTE 164 & 311 PATTERSON, NEW YORK TELEPHONE 878 -6500 ISSUED AND SUBSCRIBED BY: NAME 4 o� TITLE c— 0 IF YOU FAIL TO APPEAR ON THE DATE AND TIME INDICATED HEREON, A CRIMINAL SUMMONS OR WARRANT FOR YOUR ARREST MAY BE ISSUED. IF YOU HAVE POSTED BAIL, THE BAIL WILL BECOME FORFEIT UPON YOUR FAILURE TO COMPLY WITH THE DIRECTION OF THIS TICKET. DEFENDANT \ D (�% 1 `��f� 1' CDU.RT ti,1�i�SC7 �� AGENCY FILE C C- WHITE- VIOLATER COPY CALVARY =C;nI IPT rOPY PINK— nFFlr..F COPY PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type I PCHD Permit #f Well Location: Street Address: Town/Village Tax Grid # 6-9 - - / a. 6 9 11t/ • 101Q LF41 D /it / , Sc�� Map Block Lot(s) Well Owner: Name: Address: Use of Well: 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 S gpm # People Served "V Est. of Daily Usage M2:0 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling)^I�eepen �ExstingWel Detailed Reason ^Ele OF , /?/pv6 // for Drilling. Well Type . Drilled Driven Gravel Other Is well site subject to flooding? .. ..... ........:.............................................................. Yes No Is well located in a realty subdivision? .............. ........................ ............................... Yes No Name of subdivision - Lot No. Water Well Contractor: C,( �L L O"&(Jress: 16.2 B,,f C4k&,O koomak r CT_ Is Public Water Supply available to site? ....... . ............................ ................... Yes No ° 6- Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to' be provided on separate sheet/plan. Date: e2 C�23 9 Applicant Signature: 13iuA- . . 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 l zoy�3, . /r *?. V5" Date of Expirationrhz L - Pcr;mit is Non - Transferrable Permit Issuing Official: _. ----� Title: S 2�/SLC White copy - HD file;. Yellow copy -Building Inspector; Pink'copy - Owner; Orange copy -Well driller Form WP -97 e� r t LAK'pOR ,oy.go r G 'RO GG 117 0d viol O 05 N RON OIN i 1 N A -5'i9 A -548 A- A- 5y(o A -5y5 A -544 o, A -503 7 . N A- 5oz. A-501 ' /IPRON A -539 !N N `W , 0 A-538 A- 15W Z g Lll p A- 537 a o A- yq9 3 � A- 53(c A- 498 O. o A- 535 3 A- 447 A -4 � A- 5;34 N, 4( A- 533 A- H q 5 f — V IROU ,P-N q_532 IRON pIN A 444 SET 56T , N 84° 'SO' 60" 100.00' t A,- yq3 O (-3) 6�0;A �Aovsst�r_- m 7,10 I. SYS'ITM \VAS (0 C M) 1"HAT 'I I'll: ITAN A" S-qs-j I:f,t LiV I'l I (Wl: It' "VA", CIVI R. -1, IL cu.. -RW(_JTI) IN AU-01MANCE \X,'I i'H ALI. RUITS AND RI:.:I'I,AT!(),N.S CIF ME COLNTV I'U'UnIL I C0UnZY Department t)j kjealtL Jivision 1 f Environmental Hca:Lth Servicb,,'n_ kPprOved Is noted for conformance with •poltcabl( 11111as and p.-?gkj1ations of the �-J�,L�, 'utiiam Co i nty Health Department.; �7 13 Loa t to OF TM TM o - 'FM 4,-j X Lri A5-32; IF 3k - ,5 T_-� a c, 5 ka a C_ tfF, —pw C�FAISV-4I`& op Me 1\1tu 14 tqad :Y(--r '6x1 4 I. SYS'ITM \VAS (0 C M) 1"HAT 'I I'll: ITAN A" S-qs-j I:f,t LiV I'l I (Wl: It' "VA", CIVI R. -1, IL cu.. -RW(_JTI) IN AU-01MANCE \X,'I i'H ALI. RUITS AND RI:.:I'I,AT!(),N.S CIF ME COLNTV I'U'UnIL I C0UnZY Department t)j kjealtL Jivision 1 f Environmental Hca:Lth Servicb,,'n_ kPprOved Is noted for conformance with •poltcabl( 11111as and p.-?gkj1ations of the �-J�,L�, 'utiiam Co i nty Health Department.; �7 13 Loa t to OF TM TM o - 'FM 4,-j X Lri A5-32; IF 3k - ,5 T_-� a c, 5 ka a C_ tfF, —pw C�FAISV-4I`& op Me 1\1tu 14 tqad IVo I V��T1it►1 cap' r 4 (t �• �q' 1. 2Q � tJ� 2 oy co r