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HomeMy WebLinkAbout1403DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 33. -2 -25 BOX 13 01403 L' , I L ' 1 `� rel i � �� ' T �t� sell L ' 1 r r ! �., .. �'� ,, � 01403 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 -T - APPLICATION TO CONSTRUCT- A WATER � WELI; " PCHD PERMIT # WELL LOCATION t eet Address CS1. Town /V I Tax.Grid Number WELL OWNER N e �` Mai g Aldre2E., Private O Public USE OF WELL 1 - primary 2- secondary eRESIDENTIAL O BUSINESS O INDUSTRIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP. O FARM O TEST /OBSERVATION d INSTITUTIONAL O STAND -BY O ABANDONED ❑ OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION GI ADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING ) © DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING f WELL TYPE DRILLED DRIVEN DUG GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES -4--yo IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. °d 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 SEPARATE SHEET (date) (signatu ) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted aniier 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. Date of Issue: 19 2te it H.D. File t s'suing c a Date of Expiration: YGA, `% 19 S� Pe rmit is Non - Transferrable Yellow copy: Building Inspector Rev. 10/88 Pink Copy: Owner Orange copy: Well Driller 0� \0� \OIP P� �G '.5 - -- / O / N 41- 14- 00 E 226.00 �a / - ret.wall - - tank : / porch 2 s+i. fr. dwg, � / ret. wall ccnc.pa4 / /P p on coot A� welt � b!/ 7� drlaa // ` N39- 26 -OOE //0. 00 frame / lean -to /f out loll_ out _FENC�POST O ASE 15. / e .• - �,pIN FOUND 0 f E�S7 w i i '71 77 DF DEPARTMENT OF HEALTH ,/Division of Environmental Health Sery C s 'ROUTE SIX CENTER CARMEL, N.Y. 10512 (914) 25-0�3- (ZCI APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # St reet Address Town/Villagg/UlEy 1Sx ,ILu "UUU=& D Ig Address _dPrivate i, Name mail i-i /I " 0 Public ❑"RESIDENTIAL [3PUBLIC SUPPLY C3AIR/COND/HEAT PUMP' 0 ABANDONED (3 BUSINESS Q FARM 0 TEST /OBSERVATION O.OTHER (spec 0 INDUSTRIAL MINSTITUTIONAL 0 STAND-BY 'I, � C3 - YIELD SOUGHT gpm/# PEOPLE SERVED /EST. OF DAILY USAGE,_____gal IREPLACE EXISTING SUPPLY ❑ TEST/OBSERVATION.' MADDITIONAL SUPPLY I—- rl • ----- Vv70MT1TP LTVTT [ :TAI. -3,C: \ 1, ;-,)N �.X) ".1, , TAILED ' tEASON, FOR. DRILLING'. WELL TYPE..:- DRILLED IS WELL SITE .%SUBJECT TO FLOODING? WELL .IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Addres s IS PUEL fCaWATaER,SUPPLY AVAILABLE TO SITE: YES NO NAM ff'�TT%IC WAT ER SUPPLY: TOWN/VIL/CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION, SKETCH & SOURCES OF CONT AMINATION PROVIDED .�..'IOON SEPARATE SHEET (signature) Td- a -te) FIDRIVEN [3DUG OGRAVEL 11 OTHER YES NO PERMIT TO CONSTRUCT 'A WATER WELL ..-This permit infer the to construct one water well as set forth above is granted L v..-provisi6ns 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, 'th - appl i can e t shall. 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 p ermit. 3. provided County Completion Report on a form by the Putnam -Submit a Well Health Department. 19 Date., of Issue: Permit Is-suing Official .-Date-of Expiration: 19 White copy: H.D. File Permit is Non-Transferrable Yellow copy: Building inspector Pink Copy: owner Rexr.10/88 Orange copy: well Driller LL LOCATION WELL OWNER USE OF WELL 1- primary 2 - secondary MOUNT OF US REASON FOR DRILLING 1 WELL COMPLETION REPORT Office Use DEPARTMEN T OF HEALTH Di ision Of Environmental Health Services ('PUTNAM COUNTY DEPARTMENT OF HEALTH STRE "T AODR 5: w VI 1 1 Y TAX GRlO NUMBER: NA E ADDRESS PRIVATE ❑ PUBLIC SIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. HEAT PUMP O ABANDONED p BUSINESS O FARM O TEST/ OBSERVATION 0 OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY O YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal. 0 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST / OBSERVATION '& REPLACE EXISTING SUPPLY .❑ DEEPEN EXISTING WELL A DEPTH DATA `WELL DEPTH ft. STATIC WATER LEVEL .eft. DATE MEASURED � DRILLING ❑ ROTARY "R COMPRESSED AIR PERCUSSION O DUG EQUIPMENT O WELL POINT O CABLE PERCUSSION O OTHER (specify): WELL TYPE 10 SCREENED O OPEN END CASING. TOTAL LENGTH — CASING LENGTH.BELOW GRADE — DETAILS DIAMETER — WEIGHT PER FOOT —� DIAMETER (in) SLOT SIZE SCREEN C,9ST DETAILS SECOND GRAVEL PACK O YES GRAVEL O NO SIZE WELL YIELD TEST 1. If detailed pumping METHOD: O PUMPED t tests were done is in- �S,COMPRESSED AIR ; formation attached? O BAILED O OTHER -,OYES O NO WELL DEPTH I DURATION DRAWOOWN YIELD I ft, hr. min. 1 1t. 9Cm_ WATEi1'CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED ?`!1,yES ONO PUMPGINFDRMATION , TYPE I s, � CAPACITY MAKEA DEPTH MODE VOLTAGE HP OPEN HOLE IN BEDROCK O OTHER D ft MATERIALS: 'S STEEL O PLASTIC ❑ OTHER ft, JOINTS: O WELDED THREADED O OTHER 9 in. SEAL: O CEMENT GROUT O BENTONITE `OTHER _ Ib.lft. DRIVE SHOYES ONO LINER: OYES ❑ NO LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? n YEc n un HOURS IDIAMETER ITOP BOTTOM OF PACK in. f DEPTH ft. DEPTH It WELL LAG It more detailed formation descriptions or sieve analyses 1rY illl are available, please attach. DEPTH FROM Water Welt SURFACE Bear- 1.n FORMATION DESCRIPTION G7oE. meter ft. it. "9 In STORAGE TANK: TYPE CAPACITY St. Tr GAL. o 7279 LAB H �Yorkowm Medical Laboratory, Inc. T, -g+P TB�.PSl' tg�L .T1me : _Yorktown Heights, N. Y. 10598 Date Rc' d : Time: (914) 245 -3203 Date Reported: JUN. 191989 • Collected By: Duane Torlish Director: Albert H. PadovaniM.T.(ASCP) Referred By: (- -1 Sample Location: 64eh Ply_ TORLISH WELL DRILLING f rYl PO Box 271 PE2; Armonk, NY Phone N 273-344.8— 10504 Phon.e fl Sample Type L J Repeat Test? (check one) LA30R--' -'RJRY TREPO?T ON THE QUALITY OF WATE i I`iORGA:,IC 1,10111 - METALS (mg /L) Acidity AI ?.ali nit;, _ C- loride _ Detergents, :43AS _ HarAness, Total _ Nitrogen, Ammonia _ Nitrogen , N_J trate _ P^osphate, Total _ Sulfate _ Sulfide Sulfite METALS (mQ /L) _ Copper I: on - _- Lead _ Manganese _ Mercury Sodium Z= ^c •.1TSC=- TTA-1 -OUS _ DH (units) _ Color (units) _ Odor (TON) Turbidity (NTU) ?4ICROBIOLOGICAL (CFU /100mL) GENERAL BACTERIA � tandard Plate Count (CFU /1.OmL) ,,jE1,13RANE FILTRATION TECH',IAUE ✓ Total Coliform Fecal Coliform Fecal Streptococcus t;OST PROBABLE. `TUMBER TEC'r. ?1IQUE Total - Coliform Index.. ...... . Fecal Coliform Index KEY FOR TERMINOLOGY N/A = Not Applicable LT = Less Than (<) GT = Greater Than (>) TNTC= Too Numerous To Count CON = Confluent ( =TNTC) NR = Non- reactive REMARKS /COMMENTS (For Lab Use) _ Potable _ ,ton - potable _ S T P I'NF _ STP EFF Other. Sample Status: (check each) Outzoi- z HNO3 _ HCl H2SO4 _ Nao:. ZnOAc ?ia2S203 Other: Incam -in a h °C i/GT 4 °C pH L7- 2 �H GE o _ pH GE 12 Other. OF A THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS�) YORKNSTATENDRINKING WATER SATISFACTORY SANITARY QUALITY ACCORDING TO TH NE STANDARDS, FOR THE PARAMETERS TESTED, AT THE T E OF COLLECTIO . EET THE THESE RESULTS INDICATE THAT THE WATERDSAMFLE ( DID) YORKNSTAT N/A) KING WATER SATISFACTORY CHEMICAL QUALITY ST CODES, FOR THE PAR TERS TED, AT T.HE TIME OF COLLECTION. T1 - n- A —..w4 M AscP). Director 2 /86(Rvsd7 /87)RWE