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HomeMy WebLinkAbout1306DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.71 -2 -11 BOX 12 1 r! 11 r r 000� r. T lomi r'y- . ,` ,;, I or i 01306 :1D 4. Rev. 3/86. PUTNAM COUNTY DEPARTMENT OF HEALTH Division of EnvlronmentalHeslth Services, Carmel, N:Y 10512' Engineer Must Provide P.0 H.D. Permit CERTIF[CA OF CONST- RUCTION COMPLIANCE FOR SEWAGE ;DISPOSAL: SYSTEM..__ -. .�,. ��t��� Town or located at I" 'M"P. Block Lot Owner /appUcant -Name "Q�S�` "'�,(L -AK) . Formerly Subdivlston Name_:! A`S/a�bdv. Lot q " MaWng Address -1- y���FM .�"F tip- �D. "ZIP D `�JU4 Date Perm Iasaed ✓ �' �r /7 Separate Sewerage System built by' Consisting of 100 Gallon Septic Tank and �7 F f-CO�2 OTZ�P'(10 j,3 iz - -yJ6ke!5 Water Supply: Public Supply From Address or: Private Supply DrWed by -kEy-T i4YATT .. Address E ' I BBuilding nm A i His Erosion- . Control Been Comple,ted? Number of Bedioome Has Garb4cGddder Been Installed? N 0 1, 1 Other Requirements W- '-. ",o V . I certify that the.system(s) as listed serving the above'premises'Fare const cted essentially as shown on the plans of the completed work ( copies of which are attached)', and in accordance 'wiih the standards, rules and ie lions, -in accordance with the fil plan, 'nd e, permit issued by the Putnam County Department Of Neal h. Oats j Certified by: P.E._JLR:A. Address cenw No.. 0t6 P Z Any person occupying premises served by the above -Syftem(s) shah `promptly take such action as.may be necessary to secure the correctlon of any unsanitary condit eons Iresulting from such usage.. Approval of',the . separate,seweraye.'systsm.shsll become null andgold a soon as a pubt,: unitary'sewer becomes available and the approval of the private water supply shall Decomo.null.'ana ld'when a' public water supply becomes available.' Such approvals are subject to modification. or 'change when, In the judgment of the Commissioner,of`:Mealth, such revocation, modification or. change Is necessary. % Date �%� � —° � � B� Title . . .. — .. .... . .. { W a ` WbLL UU1'1rLL11UV rrzrvni DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only STREET AOORESS: WNIVII / 1 Y TAX GRID NUMBER: _ -� (L�j� WELL LOCATION WELL OWNER NAME: ADDRESS: �GSS A�AO PRIVATE p PUBLIC USE OF WELL 1 - primary 2 - secondary RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED O BUSINESS O FARM ❑ TEST/ OBSERVATION ❑ OTHER (specify) p INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT __5_ gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE LOO gal. REASON FOR DRILLING ❑ NEW SUPPLY. ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST / OBSERVATION REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA ' WELL DEPTH 360 ft. STATIC WATER LEVEL ft. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ^,q ❑ SCREENED ❑ OPEN END CASING. PY" OPEN HOLE IN BEDROCK O OTHER ` CASING DETAILS TOTAL LENGTH ft. MATERIALS: 9STEEL ❑ PLASTIC O OTHER LENGTH.BELOW GRADE ft. JOINTS: ❑ WELDED fftHREADED O OTHER DIAMETER — in. SEAL: ❑ CEMENT GROUT BENTONITE OOTHER WEIGHT PER FOOT 9 1b. /ft. I DRIVE SHOE 9YES ONO LIN ER: 0YES aA0 SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST o YES ONO HOURS _ SECOND. ... _ .. ._....... _ :..., .... , ... -_ ... _ GRAVEL PACK O YES O NO GRAVEL SIZE. DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST. It detailed pumping METHOD: O PUMPED i tests were done is in- ff COMPRESSED AIR , formation attached? O 8AILED O OTHER ; OYES ONO, WELL LOG If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- ing Well Dia' lin r FORMATION DESCRIPTION pOE, ft. ft WELL DEPTH ft. DURATION hr. min. DRAWDOWN 1t. YIELD 9Gm' Lane SuAace yr- 7 0�3 (l�e,u.� 6D 6 d m WATER CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY � GAL. PUMP INFORMATION TYPE < L112 CAPACITY GL . MAKER �D y L S DEPTH a- MODE 5 G VOLTA L•HP YrElLpif . %ATT & SONS, INC. GATE ADDRESS Well Drilling SIGrhMRE Rte. 311 P.R. 2 Box 171A PATTERSON, NEW YORK 12563 J PUI'NAM COUN'T'Y DEPARTMENT OF HEALT R DIVISION OF ENVIRONMEIrAL HEALTH SERVICES tzoss A t- A Owner or Purchaser of Building .2D 5s P��r4 rJ Building Constructed.by . i f%S 1 ►��r17ZSD� Location - Stree Municipality Building Type A 2 31 Section Block Lot . N/A Subdivision. Name' QZA- Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE 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, 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 immediately 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 Environinental 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 system. Dated this oZ r, vt- day of % 19-U General CbEntractor (Owner) - Signature Ross A-LopJ 17oc Corporation Name (if Co`rpj.),, AD S � YGm Lct /�-r Address wLo- n - rev. 9/85 mk Signature Title Corporation - Address 61 s' PUTNAM COUNTY DEPARItET OF HEALTH D=SION _OF _ZNVIRO1�fiAL.-- HEALTH. SER`IICES . rzoss A�-A� ��� H A23 Owner. or Purchaser of Building Section Block Lot Ross /k�►� � Building Constructed_by Iocation - Street -P�k'CT F,rzso 1 Municipality Building Type N/A Subdivision Name Subdivision Lot.# i iJTi _ GUARANM OF SUBSURFACE SEWAGE 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, 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 immediately 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 Environinental 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 system. Dated this day of 19_U Signature / Title General Contractor (Owner) - Signature R055 AL,q X) /70C - - Corporation Name (if Corp ) La Address WLan C . rev. 9/85 mk Corporation Name (i Corp.) /oS0 9 Address . EEDO �� WL' LL l,Vl "1CLL'+11VLV iCGrVRl � a DEPARTMENT OF HEALTH -- Division °0'EnviYCmmental Health Services-, - ; -• W O4 PUTNAM COUNTY DEPARTMENT OF HEALTH Office 'Use Only / •- , WELL LOCATION STREET AOURESS: 75WN/VltLAG11CJIy TAX GRIO NUMBER: GA 0� 9 , - WELL OWNER NAME: ADDRESS: VRD�S � . 20 CJ PRIVATE 0 PUBLIC USE OF WELL 1 - primary 2 - secondary O(RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED 0 BUSINESS ❑ FARM 0 TEST /OBSERVATION D OTHER (specify) ❑ .INDUSTRIAL 0 INSTITUTIONAL 0 STAND -BY ❑ MOUNT OF USE YIELD SOUGHT 5 gpm. /N0. PEOPL'E SERVED / EST. OF DAILY USAGE 1500 gal. REASON FOR DRILLING NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST / 08SERVATION D REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL DEPTH DATA ' WELL DEPTH 'J 6 d TftSTATIC WATER LEVEL _X�ft. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY Pf COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION 0 OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING, I ./ OPEN HOLE, IN BEDROCK ❑ OTHER CASING . DETAILS TOTAL LENGTH. 3 ft. MATERIALS: ffSTEEL 0 PLASTIC D OTHER LENGTH.BELOW GRADE 4� 1 ft. JOINTS: . 0 WELDED THREADED ❑ OTHER DIAMETER in. SEAL: 0 CEMENT GROUT FBENTONITE 0OTHER WEIGHT PER FOOT___ !b.lft. DRIVE SHOE YES ONO L1NER:OYES NO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (it) DEPTH TO SCREEN (It) DEVELOPED? FIRST ❑ YES ❑ NO ..•HOURS.. . SECOND _ GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST It detailed pumping METHOD: O PUMPED t tests were done is in- � COMPRESSED AIR , formation attached? ❑ BAILED ❑ OTHER ; ❑ YES 0 NO WELL LOG It more detailed formation descriptions or sieve analyses are available. please attach. DEPTH FROM SURFACE_ Water Bear- In9 well Oia- meter FORMATION DESCRIPTION G70E. ft. ft. WELL DEPTH it. DURATION hr, min. DRAWDOWN It. YIELD gpm. Surface '' y r 020 Ark 3 60 is �360� 3 WATER CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? ❑ YES 0 NO ANALYSIS ATTACHED? ❑ YES ❑ NO STORAGE TANK: TYPE CAPACITYa —l" GAL. *bTW&MhYATT SONS, INC. DATE ADDRESS Well Drilling SIGFJXTURE Rte. 311 R. R. 2 Box 171A PATTERSON,.NEW YORK 12563 PUMP INFORMATION TYPE V Al CAPACITY MAKER O V L DE:PTHZ-2' '�� MODEL �' 6 VOLTAGEzHP V-' BREWSTER- LABORATORIES,-I.-7 Lott 224 - BREWSTER, N.Y. (914) 225 -2072 SAMPLE No. 6923 SOURCE: 232 Haviland Road Putnam Lake Pattersono NY COLLECTED: April 27 1988 BY: Ross Alan BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method well 0 per 100 ml. This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. 0 April 29 1988 1 C Roy Bi it P.E. Dire or II. IV. V. VI. 1•�3T�r��l��iti1 FINAL SITE INSPECTION Date z p ,�I spec d by — ATION �,� ---/G, G .7 OWNER �cr S / 4 /," qm .F nR crTUr)rnrr1-Trlt,1 rrm .4 ! % �% `•' �% •... . S SEfivAGE DISPOSAL AREA a. SDS area located as per approved plans b. Fill section --Date of placement 2:1 barrier. LGTH WID'T'H AVG.DPTH c. Natural soil not stripped d. Stone, brush, etc., greater than 15' frcn SDS area. e. 100 ft. from water course /wetlands. SEw-AGE DISPOSAL SYSTEM a. Septic tank siz - '1,000 � 1,250 �. b. Septic tank ins evel c. 10' minimum fran foundation` d. No 90° bends, cleanout within 10 ft. of 45° bend e. DISTRIBUTION BOX 1. All outlets at same elevation - water tested 2. Protected below frost 3. Minimum 2 ft. original soil between box and trenches f. JUNCTION BOX -° ro 1 set ' g. TRENCHES 1. Len required - ��� Len installed � a -•- a G�-� 2. Distance to watercourse measured 3. Installed according to plan . 4. Distance center to center ra'„ 5. Slope of trench acceptable 1/16 - 1/32 "/foot. ` 6. 10 ' feet from property line - 20 feet - foundations 7. 'De` th of trench < 30 inches fran surface ,< 8. Roan allowed for expansion,.50% 9. Size of gravel 3/4 - 1 " diameter 10. Depth of gravel in trench 12" minimum 11. Pipe ends capped ra We, b..TPUMP ':OR DOSE SYSTEMS —71: 1: Size -of -Pump chamber. _. ......... _.. _ .. 2. Overflow tank 3. Alarm, visual /audio 4. Pump easily accessible manhole to grade 5. First box baffled 6. Cycle witnessed by Health.Department estimated flora per cycle HOUSE ' a. House located per approved plans. b. Number of bedroans WELL a. Well located as per approved plans b. Distance fran SDS area measured ft. c. Casing 18" above grade. d. Surface drainage around well acceptable. OVERALL WORKMASHIP a. Boxes properly grouted b. All pipes partially backfilled c. All pipes flush with inside of box d. Backfill material contains stones < 4" in diameter e. Curtain drain installed according to plan p, f. Curtain drain outfall protected & dir.to exist. watercours ' g. Footing drains- dischar e away fran SDS area , � h. Surface water 2rotection adequate "� :� i. Errosion controi provided on slopes greater than 15 %. 4 ic I . PUTNAM "COUNTY - DEPARTMENT OF HEALTH N:Y. OS ? " • eer to Provide Permit N (� Division of Envlronmentd $eftlth,Servkes Carmel, 1- 1n on CERTMCA OF COMPLIANCE .. t• - � Permit . 8 ,.� ' t t CONST1 IR TION RM[I FOR SEWAGE 1)ISP`OSAL SYSTEM t r (� .04 �l/ - Town or VWage 4 ZZ 7 y •SabdiylelOn Name �� /�� :c. `_ i t �;7 */� ° %% 0Q Z �. / t, . Sdbd. Lot N Ta: Map Block Lot _ A I A� ��+ n G4� Renewal ❑ Revlolon ❑ _Ownm /Applicant Name' /{ /y ofPrevioae`Approval y MaWng Address /�` f�/t'� Gf //� Towot�OJl� . /LlYp� /O gyp'• �Z •; "•,tMi, yy � 1 � . Bautiing Type /T Lot Area 4� .y A Number of Bedioome 3. = Design Flow G P D fvU'J W PCHD N tl8cstlon1e Regpulred When FN lee comploted ,Separate I Sewerage System to rnasist of �yv0.. ,Gallon septic ipik'aa _.' To be ,0,01 kacted by' , ' •:: `'• , Pdbllc-Sapply From . ` � . ! - ' :' Address" 4 • :1 � Watei SaPPU I � " or: Private- Supply DrQled _by '• - Address rn 7� Reoalremente , .Other _ 1 represent that) am wholly and completely responsible forthe des�gri, and location oR 'the proposed. sy'sfem(s); '1).• that, the,separate'.sewago ".disposal system - above described will be constructed ai.shown.on the approved amendment theie to end!'in,accordance, with the standards, ruleTan ,regu a ,ons;o e u nam j b County Department .of: FlMlth, iand that on completion tnereof a. "CertJrcate of Construction Compliance'- satisfactory to the Commissioner of Healthwill . d be ,wbmitted ,to the' Depaifmant, and 'a writ ton. guarantee will be_ iurnshed "Me owner hs successgrs,,hetri or assigns by`.the builder, thaUdid builder voili • . place ',in goody operating -conditlori any parb,oV said sewage disposals system!jdurihi ;the periotl.of two (2) y"is Immediately following thedate of .the'issu- ante of tlie?aoproval, Of the Certificate .of. Coristruct,on._.COmpfiance, of t briginal-iysteni : o any repair 'thereto; 2) that the drilledwell described above will be located'bs shown on'ttSe approved plan-and teat sa,0 well w,II:De,'In) 11 in accordance with the ft dard ule and 'repu eons • o• f 'the • Putnam County Department of ;Health t:.= Date ; 0� Signed P E. R A _ : Atldress License No, APPROVED FOR CONSTRUCTION This approval'expues twoyears .hom the date slued, unleis constwcbon of• the btiild�ng haf,been undeitaken and is revocable for ";cause oi.'may''tie a'menGed or modifietl'when,considered neg6Dfery` -by the,COmmissioner ot,,'Health,` Any'cfiange or altmat ion, of constiuctiort . requires a new' permit. roved fopOfal/Of'dOmeftit sanitary. sewage ,.and Supply only. �33 �69 1�y /1 8y7 Dat a, le us - : DEPARTMENT OF HEALTH Division Of Environmental Health Services `• TWO COUNTY CENTER - CARMEL, MY. .10512 014) 225 -3641 APPLICATION TO ABANDON A WATER WELL PLEASE PRINT OR TYPE Si icr( AUUNSS. (U ;T' l LA IAX GHIU NUMHEH 4227' UELL LOCATION C',!1 irS fold /�/�TT�.�f� f . WELL OWNER NAME. - AooHESS. ' pgIVATL l� .e'/l��i GA " !li 412,41a�.r, PUBLIC . WELL Ti Pc . C DP.ILLED DRIVEN DUG GiavEl OTHER DEPTH DATA WELL DEPTH ft. STATIC WATER LEVEL _ It. DATE MEASURED. - USE OF WELL J4 RESIDENTIAL O PUBLIC SUPPLY O AIR /COND. /HEAT PUMP O ABANDONED primary O BUSINESS O FARM D TEST /OBSERVATION! D OTHER (specify) 2 - secondary 0 JNOUSTRIAL 0 INSTITUTIONAL O aTAND -BY WATER WELL Name: .� Address: CONTRACTOR: REASON FOR UANDONMENT: //.:GG ;rao �"�os,E' 7'✓ Pn��oSFi� S�.�S )ESCRIPTION OF WORK CO BE PERFORMED: ,�JI� /ST. �� f' /��,� QR/ /7/r C :•,t�G >/�ErT�. wEG c, _ (date) j signature) PERM 1Y This permit to abandon one.water well as set forth above is granted under.provisions•of Subpart 5 -2 of Part 5 of the New' 'York State Sanitary Code and provided that: Within 30 days of the completion of the abandonment-of the water well, the applicant shall submit to the Department a certified . statement that the information delineated on -the application for this permit has been completed Date of Issue-.-. r t vet, t' J, 1 i e r � 4 > i l ♦i J Iq �ji ! �ry\ IS r st y r ' 1,7 �i f } ..i • .• : • � Yi ', . � y .tr > 1 'C e i " tl ' i (��i f� ! a y 1 i i .f :•,1: • 1 is . .:. • . t•e`i tz,.L .'� A ., r }�: f - r i t r '' r• r. 1. dd'Y o- f � w r .rr.F ~y.i• y r!t F �{i l r , 1, ,ttr r F t �, j l ���A li%trtnl4±t'JFtilf\!� Y' r t. Putnam 'County D 4 fµ a 1, t% Y epartment' of : Health Environmental Health .Services Two County Building. t.aJr Carmel;; New York 10512 1' n. L pt x t il ' y i g 4 1 J � � +, w .. ' s' ,o, l a >< 1 ilf,. �' �tJ t'•I Iy r , t� i ., ;undersigned, hereb certif Y y that.the abandon- ment of my•water: well has:been accomplished in accord- r:.. ance with the methods described in my application- for u` a water permit+to abandon said 1 well' 1 l �I !•. \t ' k�. ` � t .f5 ya . >: ^ h , .. .� , a. � w:..,>, r \ d. } ..1'•mLiyl , +,� r,ibj, IL it \ 1d }n ;�t :•(Date) (Signature) '. 0. . w .rr (Print Name) " (Address ) 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 # WELL LOCATION Street Address 0 Town Village City Tax Grid N ber = c,� -,,/City A 2 77 WELL OWNER Name AO-53'AL1,71V Mailing 2 Jai Address OPrivate GAA2� I?A�ely�t ,,V)" O Public USE OF WELL T- primary 2 - secondary 0 RESIDENTIAL O BUSINESS ® INDUSTRIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify O INSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT .� gpm /# PEOPLE SERVED3 -.SS /EST. OF DAILY USAGE -.)'-;-2a1 REASON FOR DRILLING EW SUPPLY REPLACE EXISTING SUPPLY O PROVIDE ADDITIONAL SUPPLY ® TEST /OBSERVATION ® DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING - WELL TYPE DRILLED ®DRIVEN ODUG OGRAVEL OOTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ENO NAME OF PUBLIC WATER SUPPLY: IV14 TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED _ []ON REAR OF THIS APPLICATION 11 ON SEP RAT EET 7 AAA (date) -,nature) 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.hall- 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 19� ,�- Permit Issuing f ial Date of Expiration: 1 Permit is Non -Trans fe . le White Copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Oranae copy: Well Driller 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 # WELL LOCATION Street Address Town/Village/City Tax Gri 0A 7,---Y '10019 ,� f Q - #- Number r 2,771 WELL OWNER �J.SS / Mailing Address ��' /Vly 4Private D Public U.SE OF WELL (1�L primary 2- secondary ('RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM ❑ TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED ❑ OTHER (specify O AMOUNT OF USE YIELD SOUGHT .S gpm /# PFOPLE SERVED 9-5- /EST. OF DAILY USAGE &DO gal REASON FOR DRILLING 10 NEW SUPPLY OPROVIDE ADDITIONAL SUPPLY ❑TEST OBSERVATION OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING A/1a IV / -5J %A�",. , WELL TYPE LjDRILLED DRIVEN E]DUG 'a GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name / 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 & SOURCES OF CONTAMINATION PROVIDED _ . []ON REAR OF THIS APPLICATION ON SEPARAT SHEET 3-- (date) ignature) 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 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. R Date of Issue: z 19 Date of Expiratio ;7:r 19 e ici White copy: H.D. File Permit is Non - Transferrable Yellow campy, Pink Copy: 2/87 Btuld� rig Inspector Owner Well Driller F.I?J?j al.t6 �. PU'i'NAW COUNTY DEPARdMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET - CONSTRUCTION PERMIT / �Os � S p�G✓ DATE BY: (Name of Owner) (Street Location) *W NAPE. - . -. required P - - WO fill notes Mme 9 $11 REVIEWED: 9' j DOCUMMS Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results Perc Hole Depth s/s SUBDIVISION Perc (3) Fill cd Plans Ztao sets Well letter ariance Request GENERAL. Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town/DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D o�ox;Trench /Gallery; Pump pit details Septic Tank - Size, Detail % ? Well Detail, Service Line if over Construction Notes (grinder notes) 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 Bedrooms Wells & SSDS's w /in 200 ft. of Proposed Systems 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,Top of fill 20' to Foundation Walls 100' to Well(- 200' in D.L.O.D, 150' pits 100' to Str ,- Watercourse, Lake (inc. expan) 15' to Drains - Curtain, Leader, Footing 351to catch basin,stormdrain,piped watercourse 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' rain Foundation; 50' to well 15' Well to PL 0 1...� ( (..- (((��� .� sue" G .� _� /® �,� -� DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN.uATA SHEET- SUBSUFACE S39AGE DISPOSAL SYSTEM FILE NO. Owner /� /V Address 2 S / � L!Ai�� /�v,S�D /a�i�7U / ✓�tiy Located at (Street) � �l i �S %� 'op Sec. /`/9 Block. �/ Lot A i e 7 (indicate nearest cross street) Municipality Watershed CR O 701V Date of Pre- Soaking e/ //- 8 7 Date of-'Percolation Test y- �� 7 HOLE NU1BER CIACR TIME PERCOLATION PERCOLATION gun No. Elapse Time Start -Stop Min. Depth to Water Fran Ground Surface Start Stop Inches Inches Water Level In Inches Drop In Inches Soil Rate Min/In Drop Z7 3 �� 4' 5 3 �:�� ^ -�3 y� zy zT 3 �y 4 F1 1. Tests to be repeated at same depth until approximately equal Soil rates are cbtained.at each percolation test hole. All data to-be submitted for review. 2• Depth reasurements to be made from top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRI11tION OF SOILS ENCOUNTERED IN TEST HOLES z' DEPTH HOLE NO. HOLE NO. HOLE NO. 3 G.L. --4 2' 3' 4' 5' VA 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED A/ INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP -HOLE OBSERVATIONS MADE BY: IYOR Y W.1V1C�/xS ,jl?. DATE: r/' Z' e,7 DESIGN Soil Rate Used Min /1" Drop: _ S,.D.,,Usab e Area Provided Sv�v Noe of Bedrooms 3 Septic Tank Capacity gals. Type C Jjvc. Absorption Area Provided By 3 LoF .Xi�24" w &h/ i. ench C1 =+T�f�Ja Other q�OF NEW yo` Name G/J�if?,Ci ✓T = i�c��r ✓,E,�/li� ✓�, 49csr Signature ?Li Address SEAL No. ssrZ� ESSio THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sgaft /gala Checked by Date J.3a/O.0w*7 . �7 ooa� /,a�� 0?5 572 5(,q 568 q. 51154 560 5(00 TOPO PLAN FOR ROSS ALAN SCALE:I " =30' DATUM - USCSG MEAN SEA LEVEL I P-0 - � 1'fv /•mss Y — 2 -3 G.o�) • r. ...� e� 5•' ;ie S fd+ +s so ti - ;01 ,r - -f- S ,,St M o f LONGITUDINAL SECTION -.,NOTE oo NOT INSTAL L- TKENGHVS IN WCT SOIL. -KAKE 5i!20• AND 1501-fOM OF TKCNCH PRIOR TO PLACiWi GRAVEL. ENDS OF ALL DI,5TKl5UT0R,°5 JMP .SHALL BG GAPP6D. rI �J,i1k O IO' WIOE WA-fER EAG a:ir•:. I � — T — -� TYPIGAI, ABSORPTION TRENCH. - -� Q NOT TO SCALE KNOCKOUT F , - - - -� I 9,5'DIA. INLETS ,, PINI'�FIEl7 GsRADG - -IA. OUMeTS A ���VAZ GOVCR NOTV3 VG. TO: X I I ONLY THE INL2T,; 6UTION 4�v 2�r¢ P.V.G. OUTLET AND T SIDE 11 FROM PUM I> �i GHAMP6R A 4) OUTLET`S• TO OtKNOGKC 7th Vt., A6 51IOWN s S :TANk . 'rAN 5AN .'OK PGA &KAVCL :I3W , 5OX D6- 5W NOT TO SCALE 70 r� e8�.,o�p-floU feEJ- 1oVAat.E GoVEri: 1Z7- JLEf I: -fo AuQc7rlo1,.J Ah- P�UIL1 ' nIMt:Nh10N GHA¢t N% A 6 I 20.5 3G.p 2 25.0 •41.5 3 2 %.0 4G.0 •4 34.0 50.0 5 <to.0 99.5 G A•G. S 58.5 1 59.0 G 1.0 0 25.0 -12..0 1J 2 19.0 94.0 10 34.0 16.0 II 7 %5 6G0 12 GO5 29'O 300:: Ik I- 't0• S rI 4 15 70.0 r3 � �- .12 42• 1000 GAL. 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S S• 10 1 3s. °iEPtICitANK 4•0 501.ID 8 -(HIS 15 10 Gt;2 fIFY 1HAT -THE P.V G.(fYP) WAC>E D15PO�iAL �Y51F M WA-5, 4 "mG.I.P GONr�fRUGf6D A5 INDIGA-TI✓DON -(Hie, PLAN AND TNAt tNE �i f�itEnA WA5 P' A iNhPEG fFi D PN MO ell r'01Z6 1'f WAh : I GOVE2FD OVErz.-fHF. yfyfEM WAei i2' EX1yfING GONG1fIZUGTPiD W Al.GOLZDANGr-, WI'fF,I fLByID�NGF� ALL �1ANDAIZD RVLF�i AND �EGU I ``: LA'f10N�i OF TNFi PUTNAMGOUNIY 17E -� 7AF -WFiN1 OP FiPALIH AND "f-HE- NEW G11.Ji•S1-IEI� YOIZi� 61A1ti DEPAZTMONT OF HEAL' G2 E AD - N0'(�, HOUOi� LOGA110N 'TAKEN � r . /, FZOM 'StJtz/�'( OG PROI�ER.-�-fi• Z - -tlewr P2EPAlZBD PO�ANfON10! _ loiU r ;feAG`( E. VANZO DATED 5 -�& -M Z' 111.1 (t (P, AS - bU I LT - ;. � PegPA12P.D l3i GPi2ALD L. LYNN ..' yGALFi: I " � 20'