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HomeMy WebLinkAbout1400DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 33. -2 -20 BOX 13 �, ��. ,� :� -� - , 4 1 CMG WLLL UVr1rLL11V1V tcl1rVR1 Office Use Only , DEPARTMENT OF HEALTH k` Division Of Environmental Health Services 4 PUTNAM COUNTY DEPARTMENT OF HEALTH WELL LOCATION STREET ADDRESS: TOWNIVILEMRIC11Y TAX GRID NUMB Eri- P C4,M nt F WELL OWNER NnME (V ; Y ADDRESS: 'lF /.^C, ©.PRIVATE ci CPUBLIG USE OF WELL (I RESIOEIITIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED `;� 1- primary ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (speC� s 2 - secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY.. MOUNT OF USE YIELD SOUGHT S gpm. /N0. PEOPLE SERVED _ S / EST. OF DAILY USAGE REASON FOR f9 NEW - SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST / OBSERVATION" DRILLING O REPLACE EXISTING SUPPLY . ❑ DEEPEN EXISTING WELL .: DEPTH, DATA WELL DEPTH - . � � __ -__ ft. STATIC WATER LEVEL 0%6 it: y y DATE MEASURED . ,, j! . DRILLING O ROTARY. ®COMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT O WELL POINT, O CABLE PERCUSSION ❑OTHER WELL TYPE ❑SCREENED O OPEN END CASINGS ILOPEN HOLE IN BEDROCK TOTAL LENGTH c2 L_ft MATERIALS: Q STEEL, 0 PLASTIC, oOTHEp,. ; CASING LENGTH.BELOW GRADE ft. JOINTS: ❑ WELDED 10 THREADEDh .0 OTHER. DETAILS DIAMETER in. SEAL: IRCEMENT GROUT ❑ BENTONri OOTHER WEIGHT PER FOOT 1b./ft. DRIVE SHOE DYES D NO I LINEA:OYES: Z NO°': SCREEN DIAMETER (in) 'SLOT SIZE ' LENGTH (ft) DEPTH TO SCREEN (ft) bEYOPED7 FIRST DETAILS SECOND.- •- -- -� .._... ^... o._ .... . - - -- - - ,. KQtI(Lc GRAVEL PACK O YES GRAVEL DIAMETER TOP �017t)kt O NO SIZE OF PACK in. OEPTH fL DEPTH_,,;,,...h.;: ' WELL YIELD TEST It detailed pumping It more detailed formation descriptions or sieve analyses , L LOG . are available. please attach. METHOD: O PUMPED tests were done is in- formation RDA1 Water wen ez C OMPRESSED AtR , attached? IDEPTH CE sear_ Dia- PoRMAndN OE5CAIPrION n O BAILED 0 OTHER ; O YES O NO my Imeter WELL DEPTH TION DRAWOOWN YIELD 1 0 It. hr min. ft. gpm. 35S" WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS 0 COLORED ANALYZED? O YES O NO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE ` CAPACITY GAL• ` PUMP INFORMATION TYPE CAPACITY WELL DRILLER NAME © p( A&*" a (,(,( �� ��� DATE , , , : ' `• "° . MAKER DEPTH ADDRESS �?f ' S StGflltilJRE' MODEL. VOLTAGE HP Cud �,( i1 d ryS / s {2.017817 Yorktown Medical Laboratory, Inc. LAB # - -- ,J 321 Kear Street Date Taken: Time: y� "Yo zktow.n.Heights -N Y.4059$ _ .,..., Date - Rc.'.d: � � ­ Ti-me-:: (914)245 -3203 Date Reported. •.1._ 1988 Director: Albert H. Padovani M. T. (ASCP) Collected By: Jte,,t (yesVIA4r Referred By: T_ 1 Sample Location: W-4 LL rVvA1'C� . 3 1U&4' S� L' Phone # A/ � w6lN7 /'A?' . /U� � � Phone 1i a//Yj -6rrV q I Sample Type: L i J Repeat Test. _ (.check one) LABORATORY REPORT ON THE QUALITY OF WATER INORGANIC NON- METALS (mg /L) MICROBIOLOGICAL (CFU /100mL) Acidity _ Alkalinity Chloride Detergents, MBAS _ Hardness, Total Nitrogen, Ammonia _ Nitrogen, Nitrate Phosphate, Total _ Sulfate _ Sulfide Sulfite GENERAL BACTERIA Standard Plate Count lC .(CFU /1.OmL) MEMBRANE.FILTRATION TECHNIQUE Z Total Coliform 9 Fecal Coliform Fecal Streptococcus METALS (mg /L) MOST PROBABLE NUMBER TECHNIQUE Copper Iron _ Manganese _ Mercury Sodium Zinc MISCELLANEOUS pH (units) Color (units) Odor (TON) Turbidity (NTU) Total Coliform Index Fecal Coliform Index KEY FOR TERMINOLOGY CFU = Colony Forming Units N/A = Not Applicable LT = Less Than ( <) GT = Greater Than ( i) TNTC= Too Numerous To Count CON = Confluent ( =TNTC) NR = Non - reactive _ ✓Potable Non- potable _ STP INF _ STP EFF Other: Sample Status: (check each) Outgoing HNO3 _ HC1 H2SO4 NaOH ZnOAc — Na2S203 Other: Incoming LE �GT 4 °C °C 4 _ pH LE 2 _ pH GE 9 pH GE 12 _ Other: REMARKS /COMMENTS (For Lab Use)IELAP #10323 THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS (WASN'T) (N /A) OF A SATISFACTORY SANITARY.QUALITY. ACCORDING TO T YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A) EET THE SATISFACTORY CHEMICAL QUALITY-STANDARDS OF THE NEW YORK STA DR KING WATER CODES, FOR THE PARAMkTERS TESTED, AT. THE TIME OF COLLECTION. _-.i-Albert. H. -- Padovani-,- -M.T , Director. 2 /86(Rvsd7 /87)RWE Rev. 186 CVRTMC Located PUTNAM COUNTY DEPARTMENT OF HEALTH J3 ! p Division of Environmental Health Services, Carmel, N.Y. 10512 Engineer Must Provide p.C.H D. Permit 0-L, ? F CQNSTLLTCTIONCO nn` % `O J, �4 T own or Vllleg� ✓ �i i l t o--e• T a: Map Block Lot ' ,Owner/applicant Name J.A/h C3 �'JII' HJrrp F ormerly Subdivision -Name OSabdviLot # Melling Addr - J9G l Ate AILVe Zip Date Permit Issued- ht I / r Separate. Sewerage System built by Address Z. 1 Consisting of � � D � Gallon Septic Tank and 31) le L � � � � � i� 7 f B� .G Water Supplys Public Supply From Address or: Private Supply Drilled by - Address Building •Typer� ti► L Has Erosion Control Been Completed? Number of Bedrooms Has .Garbage Grinder Been Installed? Ali) Other Requirements I certify that the systems) as listed serving „the above premises. were constructed a �entially as • shown on .the plans'of the completed.work (.copies of which are attached), 'and in, accordance'with the standards, rules and requlatio in accordance. p lan, and the permit issued by the Putnam Count Department 6f Health. T Date /�� / 'D �f C.&rtifiIad by y�i / y�� P.E.4 A.A. Address p t r t tj'nr, �Sr e- . /l CL / �! �i//t1�- �� License No.- Any person occupying, premises. served by the above' system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions ,resulting from such,, usage. Approval of the - separateawe►ags system:ehall become null and vole is soon as a pub:'_ sanitary awer'becomes avaiieble antl the aDDro'vsl of she private water supply shall become hull and,.void when a public wata supply becomes available. Such approvals are subject to modHicatio or change, when, in the' udgment of the omm lfonsr of Health, s�uelijevoeatbn, modification or change If necessary. Date 1 Title PUTNAM COUNTY DEPARTMENT OF REALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES j 93 Owner or Purchaser of Building Seeton Block Lot TAY 0 �' i�2 c.- / r x's Syr l`�ec, 4w l'p2L, � a Building Constructed by Location - Street Subdivision Name Municipality Subdivision Lot # Building Type 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 an repairs made by me to such system, except�whereJ 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--4uiiding utilizing the system. Dated this �7�'(� day of o- 19 D� Signature General Contractor (Owner) - Signature Corporation Name (if Corp.) Address rev. 9/85 mk Title rporation Name (if Co .) Add ess h ±. 1 �-T8 Al Al 3 -- k ^ y L Ar4 /� N �•�•.,.w•,,w,....... -rx rr,'^.`"'",e.. T.,:.. e:<;'. t .:",v�.�.... «�..v�p.;.. <.�n.. ar:. .p+w�isc �tr�crr- .a:.,.- r.:, .,,.... .i 7 .. � ,;,:'$'qtr �k:?S;YYY }�pn• 71yr`fn x,�" +d*"°�r'Y'�"� ';'3 `'"C 1`?w ?� = 1y�i;� y.�K. 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 # y WELL LOCATION WELL OWNER Street Address �� Town/Village/City Tax Grid umber ,er Name Address jrrivate O Public USE OF: WELL ]Q- primary 2- secondary O RESIDENTIAL PUBLIC SUPPLY (3 BUSINESS , O FARM 0 INDUSTRIAL O INSTITUTIONAL O AIR /COND /HEAT PUMP (3 TEST /OBSERVATION O STAND -BY D ABANDONED ❑ OTHER (specify O AMOUNT OF USE YIELD SOUGHT_,fp_gpm /# - 9,Cd ERVED__ /EST. OF DAILY USAGE? D gal REASON FOR DRILLING DETAILED NEW SUPPLY []PROVIDE ADDITIONAL SUPPLY ❑REPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL ofi` t d CJ �� r / ❑ TEST /OBSERVATION REASON FOR DRILLING DRILLED DRIVEN DUG ®GRAVEL OTHER [WELL TYPE IS WELL SITE SUBJECT TO.FLOODING? IF WELL IS LOCATED IN A I WATER WELL CONTRACTOR: YES NO REALTY SUBDIVISION, NAME OF SUBDIVISION• / Lot No. Name"'—/-A 64 del-e/n►,n -i1 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ _N0 NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED C] ON REAR OF THIS APPLICATION �ON SEP TE ol.0 (date) signature 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 promijed by the Putnam County Health Department. Date of Issue: 6 �. 19 Date of Expiration: —65 19 ermit Issuing fficial Permit is Non - Transferrable 0 ioc f +� PUTNAM COUNTY DEPARTM NP OF . BEAMH DIVISION OF HEALTH ppMCES _ ..... APPENDIX I _.... DESIGN-- AATAdc � crTntiS;; ' C�' S S".�..- DISPQS �1S'SM. -I _.. .. ilLt: F,� a Owner. J g M e1{ i.' V+ L, /t q.. 4)/i IAU .; P,,ddress . /oL9 Located at , (Street) G/H 6li o�,r� �a a ? Block .Lot.Cd (indicate nearest cross street) Municipality A i�rrfen Watershed �• y G. SOIL PERCOLATION TEST DATA .R.EQUIRE D TO BE SLMMI= WMH APPLICATIONS Bate of Pre- Soaking ,S 8 Date of Percolation Test 4P% `' r HOLE NUMiM Q,OCIZ TMr " PEK..O.r] CN PERCOLATI r , ON• Run Elapse Depth to Water From Water Level No. Time Ground,Surface F. In Inches Soil e: Start -Stop Min. Start . 5top Drop In kRat Min/In Drop•' - Inches Inches Inches 2't fc2 '.l . Soo .362te A ire so 19 5 SO 2/ a 3 a �s 17 2 It 17 y�: n 3Q eZ 36 / l .� ! 2 5 NOMS: 1. Tests to be repeated'at same depth until approximately equal soil rates are obtainedat each percolation test hole. All data to' be submitted for review. 2. Depth measurements to be made fram top of hole. rev. 9/85 94'ea PaAO-TddV @-TL"d TTC59 :Xm U43NMV(33a HlTqm M asn Ho a3vas SIRS ;l Or b aN // Mlas Rv tsaiy pp Ole 2;aA, '�xnqiiisTs 77, CIA 'r-4dJ0SCff 0(] T av UO. litz X .*a*q Aa PaP.AO-Tcl Va ::)r4 (39 suloox PaR -40 OR XEMI S :(307cl ..VUTN PaSLI aqvd TTOS." -[CrLIsn •-a-s...- PqPT�o:ra Paw a NDISaa I2990.2og a.. :�a 21 koo XEI aavw SNOI VAU q cm -7'. oana=OCNa oNjaa -UM.3V Sagrd MM ERM BDIHM OS rMM SMICNI Nfxxm si EstT�G�ED HDIPA XV rzjtm;21VoIwI aau3L 410 AT •CN MH *ON MOH v I P.1 70 CTPL e!? j-»c 9mmmkokNim arc m �N'lw -Mal ONG)"Pro)v w4CRAPIA", Elk, ogictla 100-c t-Wowl Im I OR aqos ITT T 19 IS IZ IT Hiaa M 000NTY 'DEPARTMENT OF REALM DIVISION OF ENVIRONMENTAL HEALTH : SERVE( hb . INDIVIDUAL M= SUPPLY & SUBSURFACE SEWAGE.DISPOSAL SYSTEMS REVIEW SHEET - CONSTRUCTION PERMIT p DATE I �lliL� U.U5�� BY: - �"(Nmme of OHmer) (:Street = ioation` = /C YES NO DOCUMENTS ° Permit Application' Corporate Resolution 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 squired 0 ft. max. Parellel to contours House Plans - Two sets Well permit; PWS letter Variance 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 or J Box;Trench /Gallery; Pump'.pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data: perc and deep results. sTwo-Foot Contours Existing & Proposed Driveway Slopes_Cut ; -4i rooting /Gutter,Curtain Drains=- (discharge- ,.OK,)-- :- •-- ..,.�- Perc & Deep Holes Located i -Representative of primary and expansion 1` Expansion Area;shown;gravity flow,suff. size `If Pumped Pit & D Box Shown & Detailed ' House - No. of Bedrooms Wells &•SSDS's w /in 200 ft, of Proposed Systems t Property.Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 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 fil' 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, Leader, Footing 351to catch basin,storm3rain,piped watercourse 10' to Water Line (pits -20') s 50' intermittent drainage course Septic Tanks 10' from Foundation; 50' to well il 15' Well to PL 9 10 N 14 Ile eo F 20.00' ° "p, PQ� °eye Rte, Z Q0 O o I'P of of Il I' �•/J�0.6 /0�� /I /i� n C p �qP D�• -� Ll���a� ,d 0 e� �� Poo o y9 a ✓� , R, 27 +' "� P Pe, to ofp ° 1g P3 I E/ Q'o E P F � �•161 r (P e c"o PP O. ✓0 P I� 113; •�'"�° IL�PJ Ry�C� • - - "' bpd �{ cP�pQ INCLUDES L07- 5c'b6 , "GORE PARCEL' L. E e o Eof�J Py '1 p, lT R� ? l! � v � n o � N �r i Ttias s %o cc,-/L4K h• sewn e. �t a e NaS consfr- e d 4 sv � 1 and�_g _ ,I i 1 m O vwE FnuND 6 WEST ®ME O O /OE GouNO .� •:O r-- iR ®0511 7 ,(/0 w OR ,piG- T A• W tsAMIKIA�� Department of Heap JAA'/ES nmental Health Servi ee for conformance with id Regiilatlons of the thD/epartment. Data : .. MMM or/girw/ of !his survey maNed w /th on original of the land orhis embossed seal sho / /be considered to be vo /idtrue Certifications hereon signify !hot this survey wns prepared in occordoixe with tte . copes existing Code of Practice for Lord Surveys adopted by the New rod. S10 /e Association of Professional Land Surveyors. Said certificatons s/ao / �rtrun on/y.10 'NE the person for whom the survey is prepared, and on Ms beholf to ttie:' t/e company 7R 41V SL : "� _ �— ` -- zm®r governmental agency -ono /endingvi�stG% .n.Js!ec±!e -ter, -, ',01;5e ossiynees'of Ytie /ending institutron. Cer >ificotions ore not Jransferob /e to addit insli>ution =�M �� 0 oh.'o/ or to. subsequent owners. Unauthorized a/terotion or odd/hon to o survey mop bearing a /icen ed /and �FBi[�ci`'LIFf�� * surveyor's seal is c vio%tion of Section 7209, Sub - Division 2, cf,lhe New Yoi Stole Education Low Underground easements, CAM structures and /or encroachments, if any, � i'ot shown her C�O1�7�Z7 Ttias s %o cc,-/L4K h• sewn e. �t a e NaS consfr- e d 4 sv � 1 and�_g _ ,I i 1 m O vwE FnuND 6 WEST ooff alQ, 6 ✓C 1u n l_oiPE o r;•o/- O O /OE GouNO .� •:O r-- �p2/✓7E,@L y , r ,(/0 w OR ,piG- T A• W `VR /G�/T' � �/�1/VIES Department of Heap JAA'/ES nmental Health Servi ee for conformance with id Regiilatlons of the thD/epartment. Data : .. or/girw/ of !his survey maNed w /th on original of the land orhis embossed seal sho / /be considered to be vo /idtrue Certifications hereon signify !hot this survey wns prepared in occordoixe with tte . copes existing Code of Practice for Lord Surveys adopted by the New rod. S10 /e Association of Professional Land Surveyors. Said certificatons s/ao / �rtrun on/y.10 'NE the person for whom the survey is prepared, and on Ms beholf to ttie:' t/e company 7R 41V SL : "� _ �— ` -- _ z -° governmental agency -ono /endingvi�stG% .n.Js!ec±!e -ter, -, ',01;5e ossiynees'of Ytie /ending institutron. Cer >ificotions ore not Jransferob /e to addit insli>ution ' YORK �� 0 oh.'o/ or to. subsequent owners. Unauthorized a/terotion or odd/hon to o survey mop bearing a /icen ed /and * surveyor's seal is c vio%tion of Section 7209, Sub - Division 2, cf,lhe New Yoi Stole Education Low Underground easements, CAM structures and /or encroachments, if any, � i'ot shown her