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���` z PDTNAM COIINTY�DEPAICPNIErPP OF HEALTH'S ' $ . '�,
�. .DlvlaSon ad Pwhoamental Hedt6 Servkbr, Ciemel, N Y 10512 = `* �� s, ' o f ,
' Lhte� Mast ProvWe r P 5 5 88
c P C H D SPeimlt N F l
OI?ICONSTRUCnoN COMPLIANCE,�06R SEWAGE,DLSPOSAL_SYSTEM T Patterson
To or
T
i3 Fair Street Ta:P 76lilock F lx -22 2
T ompson x -$�
Owner(.ppucaoi'Name; Charles & :Camille ;'F�y Snbdlvlketon Name ThomASOn
Me
Fair Street, Carmel, N:Y �p 10512 Subdv Lot X
Fee.'1Enclosed Amoun€ , .$100.00.. Date Permit Issued .' ' i
1,0./.5 %88
Separate Seweri0e Syotem boilf by Owner ' Address i
Co o{ a000 Gaflun Septfe Taal° and Of T- ,m 7i
Date ,:5,86P tember ,1a
Any' person oecupylny ,premises sr
conditlons resulting from wch',us
ed:'servingtthe above premises Were conattucted eeaentiilly de- :aho�rti an the plans of'klie colleted wrk...t copies
dance Jith'.6. itandarda rules and'.;ieguletiona, in "accorrdance vi the filed plan, and the;jieimiE' ieaued,tiy the
Certified
Aaaiesi RD9 Fair Street r t.loena No 29206
by'the at►ov0. ystem(s► sM'll .promptly` a such actbll.as m'P y tie neoe "iy to WAMm the tonretbn''Of any,unwhltl
APp►oval of tM tapa►aN fwve► iyst shall broom null and yotd :as noon as p putt 'nnitary ewer b000niis
eta ,water wDply shall become; null hd v when a publlc watw wpOly baobhiu avallabN. 8ueh approvals 'err
hsei, in tlw;;judyrtnnt or tMCo rr of,.ljralt revoeitbn;. modNkatbn or cMn k naceesiry.
1
Yorktown Medical Laboratory, Inc.
321 Kear Street
- .... ktor.r
(914) 245 -2800
Director: Albert H. Padovani M. T. (ASCP)
• r
JOHN H. PRENTISS,P.E.
RD9. FAIR STREET
CARMEL,NY. 10512
L J
77
LAB #
Date Taken: $ 30 90 Time: 10;45am
De.t- e._.Re d:
Date Reported: SEP.041990 T
Collected By: Goffill ompson
Referred By:
Sample Location: 1 C en ap
RD 9 Fair St.
Carme
Phone # 2
Phone # I Sample Type:
Repeat Test? _ ( check each)
LABORATORY REPORT ON THE QUALITY OF WATER
INORGANIC NON METALS.Tmg/LT MICROBIOLOGICAL CFU /100mL
Acidity
_ Alkalinity
_ Chloride
_ Detergents, MBAS
_ Hardnes -s, Total
_ Nitrogen, Ammonia
_ Nitrogen, Nitrate
Phosphate, Total
_ Sulfate
Sulfide
Sulfite
METALS (mg /L)
Copper
_ Iron
_ Lead
_ Manganese
_ Mercury
_ Sodium
Zinc
MISCELLANEOUS
pH (units)
_ Color (units)
_ Odor (TON)
Turbidity (NTU)
GENERAL BACTERIA
_ Standard Plate Count
(CFU /1.OmL)
MEMBRANE FILTRATION TECHNIQUE
Y Total Coliform
Fecal Coliform .
Fecal Streptococcus
MOST PROBABLE NUMBER TECHNIQUE
Total Coliform Index
Fecal- Coliform Index.
KEY FOR
TERMINOLOGY
CFU =
Colony Forming Units
CON =
Confluent (q.v. TNTC)
LT =
C = Less Than
GT =
> = Greater Than
N/A =
Not Applicable
S/A =
See Attached
TNTC=
Too Numerous To Count
REMARKS
/COMMENTS (For Lab Use)
7k Potable
No-n- potable
_ STP INF
_ STP EFF
Other:
Sample Status:
(check each)
Outgoing
_ HNO3
— HC1
H2SO4
_ NaOH
_ ZnOAc
_ Na2S203
Other:
Incoming
LE
4 °C
GT
4 °C
_ pH
LE . 2
pH
GE 9
_ pH
GE 12
Other:
ELAP No 10323
THESE RESULTS INDICATE THAT THE WATER SAMPLE (Was)�(Wasn't) (N/A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH NEW ORK STATE PUBLIC DRINKING
WATER CODES, FOR THE PARAMETERS TESTED, AT TH OF SAMPLE COLLECTION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (Did) (Didn't) (N/A) ET THE
SATISFACTORY CHEMICAL QUA Y STANDARDS OF THE NEW YORK PUBLI DRINK G WATER
CODES, FOR THE PARAMf44kSS T STED, AT THE TIME OF SAMPLE COLLEC
2 /86(Rvsd7 /87)RWE
x 1
Albert H. Padovani, M.T. AS P), Director
/M cam•
44
WELL CUMYLI;11u1V tcl;rutct
DEPARTMENT OF HEALTH
Division ,Of "' °Environmental -tTeal ' 'Sery ces•
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
STR -T AOOR�SS: WNI�I u ! I Y TAX BRIO NUMBER:
WELL LOCATION
WELL OWNER
ADDRESS:
"E
Eft O :J�/✓ / j�
ft
PRIVATE
❑PUBLIC
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL O STAND =BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
.NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DEPTH DATA
` WELL DEPTH ft_
STATIC WATER LEVEL eft.
DATE MEASURED.-
DRILLING
EQUIPMENT
O ROTARY *`54O.MPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT ❑. CABLE PERCUSSION D OTHER (specify):
WELL TYPE'
❑ SCREENED O OPEN END CASING. PEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
-TOTAL LENGTH ft.
MATERIALS: �S.STEEL O PLASTIC O OTHER
LENGTH.BELOW GRADE fL
JOINTS: O WELDED THREADED O OTHER
DIAMETER in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE -WTHER
WEIGHT PER FOOT 7 Ib. /ft.
DRIVE SHOE`I&YES O NO
I LINER: OYES ❑ NO
SCREEN
- -- DE�A$LS.�.._•..
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (iQ
DEVELOPED?
FIRST -
-
r
�..�
O YES ONO
.. — -
Ii0UFt5
SECOND
.. .
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE
DIAMETER
OF PACK in,
TOP
DEPTH ft-
BOTTOM
DEPTH At.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED i tests were done is in-
COMPRESSED AIR r formation attached?
BAILED O OTHER
It more detailed formation descriptions or sieve analyses.
WELL LOG are avaitabte, please attach.
DEPTH FROM
SURFACE
W;1ef
Bear-
Well
Dia-
meter
In
FORMATION DESCRIPTION
G7oE,
ft.
it
WELL DEPTH
ft.
DURATION
fir, min.
DRAWOOWN
A.
YIELD
9Cm.
Land Surface Surlace
�U
N
o
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? O YES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
l TYPE CAPACITY
h ,'MAKER DEPTH
:.JOEL VOLTAGE HP,,},'��
WEL� RIUjRStE SO /%/j
ADD E � /� / �j_L, SIG RE
/C , /
t PUrNAM COUNrPY DEPARZM M OF HEALTH
DIVISION OF E�JVIRO rAL HEALTH SERVICES
Charles & Camille Thompson 76 1 22'2
Owner or Purchaser of Building
Section Block Lot
Owner
Building Constructed by
Fair
Fair.Street
Location — Street
Patterson
Municipality
Frame
Building Type
Thompson Suhd:
Subdivision Name
nBn
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the location,
workmanship, materie of the sewage disposal system
al, construction and drainag
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 ariy
repairs i►tade-by-me -to. -such- systc.:., excep . wbere the failure to operate pxaperly is.
Caused by the willful or negligent act of the occupant of the buil.dir _§ ut11#11.i9
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environmental Health Services of the Pu tnari► County
Department, o Sealth as to. whether or not the failure of the system to opera.t 1.
caused by the willful or negligent act of the occupant of the bud lding ut: L °• °
the system.
Dated this
%�. day of 19 �J Signature
Title nstall r
��C�P�P-;
G tor (eer) Si gnature Corporation ,ame (if
Corporation Name (if Corp.)
7WFe—ss n
l �` IN&,
Address
rev. 9/85
9•,0 074u74
,Yorktown Medical Laboratory,. Inc. LAB - -- --
321 Kear Street Date Taken : 8/12%8 Time : 8;?Oam
R
Yorktow
-__ _ _ .11- li<�h.4 N 249 _ _
..Y .$ ate -c!.d
A ii 1, 5 MR$
(914) 245 -3203 _ Date Reported:
Director: Albert H. Padovani M. T. (ASCP) Collected By • urge 1
Refer/'red. By:
T- JOHN PRENTISS P, E. , Sample.Location: i c en. ap
Fait St.
RD #9, FAIR STREET Uarmel
IN .
CARMEL,NY. 10512 Phone #
Phone # I Sample Type
L 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
(CFU /1.OmL)_
MEMBRANE FILTRATION TECHNIQUUE
Total Coliform 1
Fecal Coliform
_ -Fecal Streptococcus
METALS (mg /L).
MOST PROBABLE NUMBER TECHNIQUE
Copper
_ Iron _ Total Coliform Index
Lead
Manganese _ Fecal Coliform Index
Mercury
_ Sodium KEY FOR TERMINOLOGY
Zinc CFU = Colony Forming Units
MISCELLANEOUS
PH (units)
_ Color (units)
_ Odor (TON)
Turbidity (NTU)
N/A = Not Applicable
LT = Less Than (< )
GT = Greater Than (>)
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:
0
coming
LE
4 °C
GT
4 °C
_ 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 THX,2V 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 MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA E D NKING WATER
CODES, FOR THE RRAMETERS TESTED, AT. THE TIME OF COLLECT_IO_N.
�-
X/ \ego/ 1, X I '
lbert H. Padovaa , M.T. ASCP
, Director
2 /86(Rvsd7 /87)RWE
F�as SZ'I'E fmseECIICN Dzte
In= tad bv.&/
T. ;ON
_
ir
YES NO —trs
�- _ . .ten n IMADA /Yi/�_ ,
Sri u�� DISPC.cAL PQCz�
a_
�S area lc� =ea as r aoorOVe3 plans
b- Fill se-c-Iticn --Date of Plac�_nt ANIG.DPT_h'
2.1 ba.rri er . LGM W-IDTDx I
C_ Fatur-°1 soil nct ricra-,
d_ Scene, etc_ , areate_r tIrT1 15' f:CI11 SDS
e_ 1G0 ft_ f- 'rat ccur_e /weti ands.
DISrCS�� Sr5-; Fin I
a. Sent, c t: Zl-k Size - 1,25G
b. mantic tz -;r'K ins =_i 1
C. 10 ` min:*n -n :- fcur=-t_Gn
d_ °0° her_ , c- =-^ -cut Wit:�in 10 f -_ Gi a_° Tc I
W-
e- DIS T_RT—E-LZIC1+ KIK
1. pji cuL--, ea.° el evaticn - wa= t�St= i
L. Prate�� �� -C:ti frCS� I
n =_1 i we°^- bCX an-C, t:n_- c:!es
3. M? T'- 1Ti1�t1 2 -f _. cric? vl- �c I
f . .--(:L,;C -P!C-N BOX = Crc ce-riv Se
j L "c'`rl re! . .►f, 3 Lc: C ^. 1P.5
L. Dist=._ ^.C� it•J. wate'� cur== ir, u f �._ I 'I
Ln 1 l _ _a`M-rc? nc to ~o
3. d Di s t�T-C° C_-tar to can ter I -�
S_c•Ce c= t.=._C 2 acc=table 1/10 - 1/32 "/fcc`.
E. 10 -cee - =uu prcre_,tj* line - 20 Lam= - ZGLrr '_CP.S I
7. L'em-Ln Cf. < 30 inc�e_= iron surGce
8. Rccn allchE. =cr r-_c_- nsicn, 50% i --i--
g Size cf c avel 3/4 - 1 diameter
1G . I;e� tz c_. c rvei in t_ ench 12" mi rL-r -m
ca-L-A
h_ FSD OR Sri crc�s I~
1 Size of r--=nm G:�:i1✓e'_ I
2- Gce_r=1cH I
3. A1�rZ, v_s`? /aLdio
C Pmz e -_ti GC_^_°Ssible jran o__ t0 cicCe '
5 • t Firs ` hcx _-! a I I
=c��i by E °_. -1 iii DEOcrr�iic ^�
6 . Cvcle w. ` I I
c� cle I
IV.
EC U,
G. b ^lLe lc < -- Le_'' aCCrcved pl -GTiS. I
b- cf boors
V. as r rorov A plans I I
a_ ;ti_cj . 1ccJ i a
b_ G re C
r°-CCrC f
c_ C=sina 18" Lcve cra^e-
d_ S=- faca dra_ _.c` arcurc wzll acc =of=�le_ lI
C-.. E-.YeS prcLG_-r crcut
b. i=,es L = vial l v hacil i �;
C. A? pices f -� : with inside of hcti
d. Ba•`�;11 s.� t ccntri ns stones < a" in di�*net
e _ C=--�� i n d=--;- ins t�1 -1 ed accordinc to plan
f. C+r" -in dr _ cutfall prctect� & dir.to evist.s�Gt�rc2LIL e---f-
d, -:- c__c.arce awav frGm SDS are
c . r �ct�na �' - ' ` �'
h _ S:�rac. wat Crct1' _ic 1 ade� to
Crcv1G =C cn sioCes Cz
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V)/ a
PMAM COUNTY DEPARTA�NT OF HEALTH
)L\ Division of Environmental Health SevlDes Caemel, NY, 10511 Engineer tofProvlde.Pormit q ;
-vv
*t. CERTIFICATE OF CO CE ' rt
a
COP(Mlq PERMIT FOB SEWAGE DISPOSAUSYSTEM
R„ T Patterson _ f
t•. _ _ Teen o 'lllak '
SabdivkiMn Name Th Omp s On ° So
b4 Lot q r t B r -Ta: Map 6 ` Block 1 , Lot . 2 2 2 '
. r -
Ownei7Appllcant Name Charles & .:Camil'=1e Thompso "ri S
Date of Pievioas tlpproval °
Mown :Addree ®" Be =rryshire Road Town
Win
gdale, NY' �p = 12594
B; _
r fti J
g�,g nPe Frame Lot Area 1 Acre Fill Section On[y Depth Valame
Nursi �f leirwms
Three - °� 60Q PCHDNotiflcatlontRegnlredWbenFllllscom leted
Des n Flow G P D
4 1000 333' wof Trenches
. Separate Sewerage System to consist of Gallon Septic Tank and _
To be conetrdcted by =` Owner AddMS same 'aS .,abOVe ? g
Water ;u Ptff►Iic:Sapply From Addres ®'
X :P ":F ^Beal &Son `' P 0 "..Box, 'Brewster, `NY 10509'
or Privatd`Sapvly:Diilled by A�adreee
Ot6er:Resaire>eenta Nonr
t lam wholly and completely responsible for the design and location of the'ip►oposeG system (s) 1)'that the separate sewage disposbl system
I represent tha
S r -
Y F N to and- �n "accordance with' the_standai s rules an r.egu a: ions o e ' u nam
aDOVe2descnbed 'wJl be constructed�as shown on the'aPprovedamendment there.
County:' Department of - Health -'and that on comD�etwn thereof a Certitwate of Construction Compliance' satisfactory torthe Commissioner of Healthwill "s
be sulimdted ,fow the Department land a :wntten guarantee will be tdin�shed`tlie owner `his wccessors,'heNS or ass�yns by the bu�lder,'that saidbwldei "'Wfil
place in good opersting''conddion an`y part of said sewage,`disposa t ystem,,Gur�ng the,periotl of two (2� years immediately following the date''of the issu-
•' ance.,of the approval af. "the Coriif�cate ot. Constiuchon"gComplionce; of the- oiig�nal system o► any repa�rt the►eto� 2) that fhe drilled:�'wel4,described abOVe ..
will belocatad ad ShOwre -on the approved plan and that�sa�d well "will be installed �n�' rdance with" t stand s rules and..iegu as 1Ti'ons of 4�the Putnam,,
County, Department of Health
Oats 9 rOk t 198$ Signed a s P. E X ' R A tY
Fa'ir. St Carml „' Y...... 10.5:12. License No 29206
PF
ass?constiuction of the building has Deen undertaken and as
stoner ot, Health Any Cho nye or,alterajign, of construcffon
eater pIY o ly: - _ 3
T. itie ��' i
.
APP=Tx B
PUrNAM COUNTY DEP.ARTMERr OF HEALTH - DIVISION OF ENVIRCNMENTAL HEALTH
SERVICMS
INDIVIDUAL MATER SUPPLY & S'JBSMMM SZQk=L DISPOSAL S'ISTEMS
KhVIEW 5-d - CONSTR=ION PERMIT
DATE RLETV ED : �d
BY:
(Name crf CWne--) (S tr eet LCC3t1CR)
YES
I NO
DCCtIlOUS
Pernit Application
Corporate Resolution
Plans - Three sits s's
Engineers A_uthorizaticn
Design Data Sheet (DCS) SU'BDIVISICN
Deep Hole Log Perc
Consistent Perc Res•,f is (3) Fill
Perc Hole Dept's ca
House Plans - Two cad=
Well pe_rmi t; VP;vS
Variance Reo-uest
Cr'-I. y-ERPL
Legal Subdivision
Subdivision Approval aerkr
fig- approval SSDS Ate= Lots Che fca
Wetla_ nd (TcwM/DEC Ps_-mi t R & D)
Data Cn DDS Plans & Permit Se,e
I REQUIRED, DETATT S ON PTA -NS
Sedage System Plan - ( north a=: C; )
Storage System Hycraul i c Prof _ley- Cray tv F' cw
Fill Profile &Dimensions - VoitTi
D o ;Trench /Gallery; Pmrp pit devils
Septic Tank -Size, Detail
Well Detail, Service Line it ever
y
- - --
Design Data: pert and deep res -,i] is
TWO -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footin/Gstter,Curt�ain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary a-rid e - pansion
Expansion Area; shown; gravity fla�v,sufi. size
:If Pimped Pit & D Box Shoran & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 _. C. f Proposed Syst`n
Property motes & Bounds
House Setback Necessary (Tight lot)
House Seger - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTAMES SPECIFIED ON PLAN
Fields
10' to P.L., Drive-Hay, Large Ttees,Top of fi.
20' to Foundation Walls
100'.to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. ex`x:
15' to Drains-Curtain, Leader, Footing
35'to catch bas.L LQrndrain,airei watercou_.
I
i
i
I
i
�
ZF
L' `enc:l proviced- ' '
ream.= ea
60 f t. ma:;.
Par contours
0 e`er-
I
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(
I
(
I
Go.�i�
I
°""°
F?' T. SYS
---
clav' ier
10 fL.
filY notes
r. spec.
-- -.
etnth gauges
--
L00 yr. flood elev.
•
?00 ft. reservoir, etc.
.50 ft. trigall /. 1.
5�_
eor
10' to Water Line (pits -201)
50' intem- mittent drainage ccurse
SeD_tic Tanks
10' fran Foundation; 50' to will
15' Well to PL 9
oe
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 # ' Q0
1 C "t Tax Grid Number
WELL LOCATION
Street Address
St.
Beal & Sons, Inc.
Town Vil age y
—T:— Pat ter s on- - - -- ------- -76 -1- 22.2 -- ---- - - - - -- -_
_.
IS PUBLIC WATER SUPPLY
Fair'
Name
Mailing
Address
CPrivate
WELL OWNER
Charles & Camille Thompson,
Berkshire Road Win dale NY
12594 O Public
USE OF WELL
I RESIDENTIAL
O PUBLIC
SUPPLY ❑ AIR /COND /HEAT PUMP
O ABANDONED
1 - primary
O BUSINESS
O FARM
O TEST /OBSERVATION
[]OTHER (specify
2- secondary
O INDUSTRIAL
0 INSTITUTIONAL O STAND -BY
O
AMOUNT OF USE
YIELD SOUGHT
Five gpm /# PEOPLE SERVED Six /EST. OF
DAILY USAGE 60.0 gal
REASON FOR
NEW SUPPLY
O PROVIDE ADDITIONAL SUPPLY
O TEST /OBSERVATION
DRILLING
O REPLACE EXISTING SUPPLY
® DEEPEN EXISTING WELL
DETAILED
REASON FOR
New Construction
DRILLING
WELL TYPE DRILLED DRIVEN ®DUG GRAVEL ® OTHER
IS WELL SITE SUBJECT TO FLOODING? YES g NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Thompson Lot No. B
WATER WELL CONTRACTOR:
Name P.F.
Beal & Sons, Inc.
Address:P.O. Box B, Brewster, NY
0509 --"
IS PUBLIC WATER SUPPLY
AVAILABLE
TO SITE:
YES X NO
NAME OF PUBLIC WATER SUPPLY:
TOWN /VIL /CITY
DISTANCE f0`PK0YE('1'Y FROM NEAREST WATER MAIN: Over One Mile
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED(See Dwg.I'ob# S.0.2474, By John H. Prentiss,
O ON REAR OF THIS APPLICATION O ON S P TE SHEET,,-7 P.E.)
9 August 1988
(date) 0sfinatuf6)
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 DepartTgnt.
Date of Issue: 19 Issuing ficia
Date of Expiration: White copy. H.D. File
Permit is Non - Transferrable Yellow copy: Building Inspector
Pink Copy: Owner
2/87 Orange copy: Well Driller
DIVISION OF.ENVIRCNMENIAL HEALTH SERVICES
DESIGN DATA SHM-SMUFACE SBqXM.DISPOSAL SYSTEM FILE NO.
Address )
Owner '000�� 0.
Located at (Street) be Pt, (I Sec. Block Tot 2 >-,
(indicdte dearest cross street)
Watershed C—L=32ka, ✓
Municipality
SOIL PERCOLATION TEST DATA RBDUMM TO BE SEJBKI= WITH APPLICATIONS
D ate of Pre-Soaking Date of Percolation Test es -C/—ae5
ROLE
NLMM CLOCK
TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Water From
Water Level
No.
Time
Ground Surface
In Inches
Soil Rate
Start-Stop
Min.
Start stop
Drop In
Min/In Drop
Inches Inches
Inches
1 190D -93v
3d
2 J3q -jftQ
33o
zo Z5
S
3moo to*!;,0
-4 jp-ko- 1) v-0
-7- 1 - V's E— E —1 . 0
3
4
5
—2 30 60
3 loll' 1045 :0
4 mqf-ti is
5 r.
NOTES: 1. Tests to be repeated'at same depth until APPradmtelY equal Soil rates
are obtained at-.-.each-- percolation test hole. All data to'be Submitted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
9
TEST PIT DATA RDQUI7
'
DESCRIPTION OF
;DEPTH
4 L
HOLE 140.
G.L.
2'
3'
Der �'Vt
41
2
5'
6'
_��, oil �00a V,\
71
a
10'
11'
12'
13'
14'
TO BE SUBMITTED WITH APPLICATION
rLITICAT% TiEV AT'jhiii�a'a—�'t'w' a an ua' i — - • vi 1
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTM BEING EN00UNTERED
DEEP HOLE OBSERVATIONS MADE BY: �v� �Y DATE
O� DESIGN
Soil Rate Used 0'� () Min/1" Drop: S.D. Usable Area Provided 0M)
No. of Bedroans 3 Septic Tank Capacity 10Go gals. Type /45D ant ,
Absorption Area Provided By L.F. x 24" width trench
Other
Name
JOHN H. PRENia.... ..
Address RD9 FAIR ST 914 - 874 -c.
I'lYlAil 'eti vnev +n_ Tt
No. 29
THIS SPACE FOR USE BY HEALTH DEPARTMENT 0 THES
Soil Rate Approved sq.ft /gal. Checked by Date
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