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HomeMy WebLinkAbout1550DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -4 -49 BOX 14 J � f 1�1 '���T .91 . m ' �6 F . '_ 01550 PUTNAM COUNTY DEPARTMENT OF HEALTHY Rev. 3186 (\ Division of Environmental Health Serviced, Carmel, "N.Y. 10512 p \•cf . Engineer Must Provide \ P.C.H D Permit #= CERTIFICATE. OF CO. U.CTION COMPLIANCE FOR SEWAGE,DISPOSAL SYSTEM /'l /_% ./ €;CS O ✓ Town or VWage q Located at NUG � .t dC ,��/J�/f/ �/_T� T. Map 7? Block- _�_ _Lot v c Owner /applicant Name A/ ' /lLa f r�EC w�,e E Sabdlveton Z"me yE� �S� ub dv. Lot N Q O E,y. N y Permit Issued MaWng Address 060 x �,S TitT�S Date Separate Sewerage System ballt byEy�EE �O W Address Consisting of I 0c:>0 Gallon Septic Tank,and ,2 04 Water Supply: Public Supply From Address or: Private Supply Drilled- by - Address /1%7 Has Erosion Control Been Completed?— y�S Building Type - Number of Bedrooms J Has Garbage Grinder Been Installed? /1%d other 'Requirements ' f'��lP �� % �l T �• O. .Q. /LL I certify that the system(s) as listed serving the above premises were constructed, essentially as shown on the plans of the completed work ( copies of which are attached), and ib.accordance. with the standards, rules and regulations, in accordance with the filed plan, and the permit issued by the Putnam County Departme t Cif Health. - Date 7141 t10 Csrtif{ed by —'a "' P.E. k R.A. Address EL ✓AJ-T. La • 12R /Jd /V• • License No. d a Any person occupying premises served by the above systems) shall promptly take such action as may be necesury to ificure the correction of any unsanitary conditions resulting :from such usage. Approval of the separate sewerage system shall become null and void as soon as a pubG: unitary sewer becomes available and the approval.`of the private water supply shall tiecoma'null and void `wAen 'a, public water supply becomes available. Such approvals are subject to mo fltatlon or change when; in ,the judgment of the CorimisslVer of Health. such revocation, modification or change Is necessary, —e/�!" ��" —�' Title Oats �� � � Y -- . . elf COn WLIJL UUr1rLz11Un r%xlrvlx.L DEPARTMENT OF HEALTH Division Of Environmental Health Sdfvices PUTNAM COUNTY DEPARTMENT OF HEALTH Office Us I e Only WELL.LOCATION STREET AOURESS: TAX GRID NUMBER: W ELLOWNER NAME: ADDRESS: SCA 0i CL r,7- e PRIVATE 0 PUBLIC 1 imary 2 -secondary _dRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/CONDjHEAT PUMP ❑ ABANDONED 0 BUSINESS ❑ FARM.' ❑ TEST/OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ AMOUNT OF USE. YIELD SO . LIGHT gpm./NO. PEOPLE SERVED /EST. OF DAILY USAGE _164 �00 gal. REASON FOR DRILLING 6 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST/OBSERVATION 0 REPLACE 'EXISTING SUPPLY 0 DEEPEN EXISTING WELL 'DEPTH DATA WELL DEPTH WE 300 ft] STATIC WATER LEVEL %a2 ft. I DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY. 9COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. 16PEN HOLE IN BEDROCK O'OTHER CASING DETAILS TOTAL LENGTH ft- MATERIALS: - _5?STEEL - 0 PLASTIC 0 OTHER LENGTH.BELOW GRADE ft. JOINTS: OWELDED eTHREADED OOTHER DIAMETER —in. SEAL: 0 CEMENT GROUT dfBENTONITE POTHER , WEIGHT PER FOOT, lb./ft. DRIVE SHOE RYES ONO I LINER:OYES NO -SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (It) DEPTH TO SCREEN (ft) DEVELOPED? FIRST 0-YES-0 140- HOURS SECOND GRAVEL PACK 11 YES 0 NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH —ft. BOTTOM OEM — It. WELL YIELD TEST 1, If detailed pumping M§rHOO: 0 PUMPED 1 tests were done is in- if COMPRESSED AIR ' formation attached? ❑ BAILED 0 OTHER ❑ YES ❑ NO It more detailed formation descriptions or sieve analyses LOG are available, please attach. , NWELL DEPTH FROM SURFACE 'Water pear. fig well Dia- meter In FORMATION DESCRIPTION CODE_ WELL DEPTH It. DURATION hr. min. DRAWOOWN ft. YIELD land Surface 6 �2 Q cc dP"-Oc�k ,300 K C�'Io_.20 3 00 7- WATER 12(CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS 0 COLORED ANALYZ ED?. - 0 YES ONO ANALYSIS ATTACHED? P YES ❑ NO STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION, TYPE CAPACITY ALNWWWATT MAKER 6rLU1dFr­S DEPTH C2 aQ MODEL 51 P -2- Z2 - VOLTAGE 0HP & SONS, INC. DATE d/ ADDRESS Well Drilling SIUATURE Rte. 311 R. R. 2 Box 171A PATTERSON, NEW YORK 12563 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISIUN OF ENVIROi�TAL HEALTH SERVICES er or • chaser of Building y� z. ding structed by Location - S Par-i�I,q�" Municipality Building Type Section Block Lot Subdivision Name Subdivision Lot # 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 "Gertficate: of Construction Compliance" for the sewage disposal system, or any repairs made by me to such system, except where the 'failure fb operate prroper y "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 system. Dated this day o� L 19-,W Gen #61 Con for (Owner) - Signature V1 Corporation Name ■w (if Corp.) Address 16&- rev. 9/85 mk Signature D/0�""' A Title ��-� GLs�✓ Corporation Name (if Corp.) dZQ ZZ _r Address PITPNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL.HEALTH SERVICES or er of Bu' ing Section Block Lot ding ds tructed b Location , -� Street V Subdivision Dame 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 44i by 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_dsposal_ system, or any s 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 19CFF 1 Gen c or (Owner) - Signature Corporation Name (if 1 �, , �✓� WI 67 1 Zl /V/.�' C/ cwress ps rev. 9/85 mk Signature Title Corporation Name.(if Corp.) ess •-cwt V >+.F. --.y -^ ._�_- ..-.,- PUTNAM COUNTY DEPARTMENT OF.HEALTH Division of EnvfeonmentsiHealth'Services, Carmel; N.Y. Engineer to provide Permit # { - on CEBTIPICATE OF COMPLIANCE:. - Permit "H' CONS U _ ON PERMIT FOR SEWAGE _DISPOSAL SYSTEM t p Located'at �o *n ,Village - ,. Subdivision Name C, o r' r .o "� uhd. L rN 9 02 �. —S —� Ta:lYlspBlock Lot, Owner /Appllcent Name � Qesf' Y � �o,?e6— R evision ❑ c� / `✓ �`,c Date of Previous Approver Mailing Address �, p , o /J!c (a p SL . Town_ Oryl� ��� / �p /,6 .O I( /. � _ E' Area. '. t • : —� , O ,ice > � Built" TYPE , Lot '/4d FID Section Only Depth; Volume - Number of Bedrooms Design Flow G . P Ij'. �� t�t� PCHID 1Votiflcatlonis Regalred When Fill to completed Separate Sewerage System to Condit of �0 Gallon Sepfic•Taalc and Dd OT /eT " �/ T—�LGGG� To 'be constructed by ��O,QGl� /O b✓�GL Address Water Suppb: LK : b7. ay Fm G Address or: -Private Supply. Drilled by Address Other Itemalrements - XY'l d .1 represent that.l'am wholly and;completely'reiponsible for ttie desigin and location of the: proposed system(s) .ii 'that the- separate sewage 'disposal system :. above described will be construeted'ss shown on the approved amendmentthere .to 'and ihaccordance w' ith the standartlg; rules an regu a ions.o. - e Putnam 1. 1 1. County Department of .'Health, and that on completion thereof a "Certificate of it Compliance" satisfactory.tov the Commissioner, of Healthwill be submitted to the Department, and :a written guarantee will, be - furnished the Owner, -his successors, -heirs or assigns by the builtler, that said builder Will - Dlace in good. operating condition any part of said sewage _disposal system, during the period of two ( ?) years, immediately following thedate, of the issu- ance •of the. °approval of the' Certificate 'of- Construction Compliance of .the original system or any repairs thereto;'?] that the'drilled well described above Will be located'as.shown on the approved plan and that said well will be instal 'n cc rdance -'wit stan di, rules and. regu a i'ons . of the Putnam County'Departm nt f. ealth - Date Sdgned Rn . P R A. _ - .Address- Off ddress License No : APPROVED FOR CONSTRUCTION This, approval :expires twoyears9romttie.date issued unless construct�ono1 -the building -has been�ungertaksn and is ►evocable for cause or-May be;amended..ormociiiied when consider id, neceiiary, *by'the'Commissioner. of'Health. Any change or alteration of construction requires .a w.,permit. Approved for .disposal of domestic, sin dtary ewsge, an r pri t .w r .su ply only. (�> Date L Q y �/ �9��?' '' -=�L Title �- - -- _ PEYINAM COUN'T'Y DEPARTMENT OF HEALTH DIVISION OF ENVIROMaML HEALTH SERVICES IN, DESIGN DATA S=-SUBSUFACE SEWAGE DISPOSAL SYSM FIM NO. Owner .o ;c So 2v ewes Address ,e 7 Located at (Street) Sec Block a Lot 11,R19 .(.indicate nearest cross street) Municipality A�,es, ,OA l Watershed SOIL PERCOLATION TEST DATA R=T= TO BE SUBMITTED WITH APPLICATIONS Date of -Rie=Soaking e 7-- Date of Percolation Test SOLE NUMBM C= TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min/In Drop Inches Inches Inches 5 (22 1 -4'yr --?o .21 123 .2 2 34lo ae" 11223 3 4 • 5 5D 4 '5: N=: 1. Tests to be repeated at same depth until approximately 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 bole. rev. 9/85 2 /, moo A ao 21 5 (22 1 -4'yr --?o .21 123 .2 2 34lo ae" 11223 3 4 • 5 5D 4 '5: N=: 1. Tests to be repeated at same depth until approximately 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 bole. rev. 9/85 INDICATE LEVEL AT WHICH CakO0MVATM--IS'ENC0UNq=" *0 7- INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED, DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used o2 e Min/1" Drop: S.D. Usable Area Provided f No. of Bedrocms Septic Tank Capacity 000 gals. Absorption Area Provided By OC) L.F. 9E 24" •-;-iA4-h . tx-ep&h 0 Other. d� �X Type &-,OA/(Z-. 7-,,e; - 6�4444--q Nam Alavie/, Signature —AAz� A AnA f Pz,,Lr- Address SEAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft/gal. Checked.by Date TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO... HOLE NO. HOLE NO. G.L. 11 Me-5 0/Z— 0 /Z 21 31 41 51 > 61 71 81 91 10 12' 13' 14' INDICATE LEVEL AT WHICH CakO0MVATM--IS'ENC0UNq=" *0 7- INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED, DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used o2 e Min/1" Drop: S.D. Usable Area Provided f No. of Bedrocms Septic Tank Capacity 000 gals. Absorption Area Provided By OC) L.F. 9E 24" •-;-iA4-h . tx-ep&h 0 Other. d� �X Type &-,OA/(Z-. 7-,,e; - 6�4444--q Nam Alavie/, Signature —AAz� A AnA f Pz,,Lr- Address SEAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft/gal. Checked.by Date APPENDIX PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL r. E. SUPPLY •E SEMGE DISPOSAL SYSTEM 5c REVIEW SHEET - CONSTRUCTION PERMIT . DATE REBY: tion) DOCUMENTS 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 - Two sets e71 permit; P'WS letter lance Request 1 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 S stem Hydraulic Profile - Gravity Flow Fill o 'le & Dimensions - Volume D o ;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 Pumped 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 "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 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake Unc. 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' fron Foundation; 50' to well 15' Well to PL _NEW' �u �,�� R;11.16PU le(O,' M11 Y,FAKIN MUM EVE MM trench LF provided required Parellel Nis .- MM tion) DOCUMENTS 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 - Two sets e71 permit; P'WS letter lance Request 1 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 S stem Hydraulic Profile - Gravity Flow Fill o 'le & Dimensions - Volume D o ;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 Pumped 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 "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 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake Unc. 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' fron Foundation; 50' to well 15' Well to PL ti /1 tr s ENGINEER TO PROVIDE PERMIT # '(( PUTNAM GOLJNTY DEPARTMENT OF HEALTH T - ON CER• FIC .E :0 OMPL-IANCE'� Orvision of- `Environmental Heahh ;Services Carmel N Y 10512 PERM I T '. CONSTRUCno PERMIT FOR SEWAGE DISPOSAL SYSTEM /}TTE�On/ .2 _ _ o Es ` ` O -� Lted }Tax Map o / ^9locic own: o illa9e[ot oZ�_ Subdivision J �� - `.. .' �Subd Lot R Renewal Revision .. .. r - ❑ ,. Owner /Address - '/ �e. azE ..0 Q%� la A �!`I Date Of Previous,,APpr.Vdl Builtling'T.YPe ��� -b Q Wit Lot Area n i' Pill :Sectio _ / i Number of Bedrooms Design Flow G /P /D �+ D O P.C., H. D Notification Required / :^ Separate,:5ewerage';system do consist of ,/ OOO Gal Septic Tank,'. antl s To be constructed by T d�'f'�~ ET 'Address Water 'supply:': Public. 'Supply From n ,/ 4rwate supply to "be drilled .. Address Other Requirements /+ = .X 7 �V�%� [�L7/T%%� �✓ i% / cry," '�V/�10 , I4epresent that I .am wholly antl completely responsible for the tles�gn and location of the. proposed system(s), 1)'. that the separate,sewagef disposal system above described .will be :constructed-as shown on •the? approved: amendment'. there to -antl in:accordance.withahe staridards, rule's an [,_egu a lons'o e. Putnam. County ; Department of Health and that ort completion thereof a `CertI cafe „qf; Construction Compliance' satisfactory to the Commissioner.of .Health will be submitted •to the .Department, ;antl a writteri,guarantea will De '_furnished the.:owne[ hissuccessors, heirs dr assigns by the 'builder, that said builder will place in good operating :tonditior, any part of salgr. sewage,•'disposaf'system during ,the period:.of tw6,(2) years. Immediately following thedate.of the 'issu ance of•the app►vval 'of; the Certificate of ConstrucUOn "Compliance'�of tKenriginal`system or any repairsthe►eto 2j'that the; drilled well described -above will be located as shown "on the approved plan antl that'said well will be, installed "in :accordance with •the 'standards, inlet' and regula ns - =of the Putnbm County Departmerit of Health Date `� I .� //1 �/_ ✓�' Y "� bOtrY signed P.E. Address 9 EL't�iN1= L•�' .Q.QrroN %% �/ ���Z' LlcenseNo APPROVED FOR CONSTRUCTION:" This'approval- expires one year -from the date issued unless construction 'of the building'has been undertaken and' .is eyocabie,for'cause`or mayaie amentletl ormodifiea when- considered necessary sby the :Commi'ssioner of hlealth: Any ',change or, alt erstion_of:conitruction. requires a' new permit' Approved:,for disposal of domestic �sanftary 4ewa4e _466/or ivate, water supply only: Date[. -" Ale .Rev. 6 /8S m DEPARTMENT OF HEALTH Division of Environmental Health Services A TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 1 APPLZCATI.ON- -- DLO- CONSTRUCT -A WATER!:WELL :.- - _ PCHD PERMIT IS WELL SITE SUBJECT TO FLOODING? YES 1--' NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: .5'7D1v-4__ Lot No. WATER WELL CONTRACTOR: Name IV07- "oo re'py yam.- T -Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES I/ NO NAME OF PUBLIC WATER SUPPLY: /✓ /� TOWN /VIL /CITY DISTANCE - -TO PROPERTY FROM NEAREST - WATER MA.IN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED - /Z 7 Z2-Z []ON REAR OF THIS APPLICATION date PERMIT SEAPR (s ign#ure 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. Date of Issue: _3 19� _.�.- Date of Expiration: a ,5:,, e ' 19 Permit Issuing f icial Permit is Non - Transferrable Street Address Town /Village /City Tax Grid Number WELL LOCATION 04 cs d. o.✓ 7 9 - - WELL OWNER Name -- // Address rivate SC�1W�%/��� O. Bc Sorg-, 0 Public .• / p/ . O <S A1. USE OF WELL >fRESIDENTIAL ® PUBLIC SUPPLY O AIR /COND /HEA P 0 ABANDONED 1 - primary ® BUSINESS O FARM O TEST /OBSERVATION ❑ OTHER (specify, 2 - secondary ® INDUSTRIAL O INSTITUTIONAL O STAND -BY' AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE ,800 gal REASON FOR EW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION DRILLING O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED ODRIVEN ®DUG ® GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES 1--' NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: .5'7D1v-4__ Lot No. WATER WELL CONTRACTOR: Name IV07- "oo re'py yam.- T -Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES I/ NO NAME OF PUBLIC WATER SUPPLY: /✓ /� TOWN /VIL /CITY DISTANCE - -TO PROPERTY FROM NEAREST - WATER MA.IN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED - /Z 7 Z2-Z []ON REAR OF THIS APPLICATION date PERMIT SEAPR (s ign#ure 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. 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