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BOX 15
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01712
Rev. 3/86
CERTIFICATES OR CON!
Located `at
�.,ii
Melling Name —!L41
Q
Mcng Address 6 ,u
:<.: _.:'..�.,r R.,t � � >M� �.i-.� 5� . <t�:�: .�.r,Mt.....�..3...�a .. „ . r..r. R z. R ; kt'�• �,1-;
PUTNAM COUNTY,DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Mast Provide (, •_ - 4;"%
P.C.H.D. Permit fj - --�
'RUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM A 4z.,.� d>y
Town or V
Tax Map -% r. BI k Lot _
Ad A e Formerly Subdivision Name It' t 1 Jr: Sabddvv. Lot #
Zip 0 Date Permit Issued
Separate Sewerage System built by
Consisting of Gallon-Septic Tank and
Water Supply: Public Supply From '+ Address
or:
late apply DrWed by � i* I t Address rll Ka �. t. )w S K gr
Bnddin e i 1 Has Erosion 'Control Been Completed? %lam
& T,p
Number of Bedrooms Has Garbage Grinder Been Installed? a'
I
Other Regnlremente
I certify that the system(s).as listed serving the above premises,were.cohat cted essentially as shown on the plans of the completed work ( copies
of which are attached),, and tin accordance with the standards, rules and re u Lions, in ac ordance with the led lan, and the permit issued by the
Putnam County Department Of health.' /
Date �:Z�-� miff y P.E. y' R,A.
,,7 AE ki License No.id�—
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 sueh usage. Approval of the separate sewerage system shall become null and void as soon as a puW% sanitary, `fewer becomes
available and the approval ofIthe private water supply shall become null and , void when a public water supply becomes available. Such approvals are
subject to odifiration,or change when; In the judgment of the CommissioneL-of_Health, such revocation, modification or change Is necessary.
Date 7 BY' / It Is
{
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Building Constructed by
Location - Street Subdivision game
Municipality Subdivision Lot #
Building Type
GUARANI OF SUBSURFACE SEKAGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the location,
woAmnship, 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 Departement 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 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 a L day of
19 1�2_ Signature,
itle
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
p.0A0X IE8 -GiNC0(LA(4 CC /V. Y. /05910
Address
rev. 9/85
mk
Vt P,
Corporation Name (if CorP.)
� :13oK X05; 'B.,jZjC_y H;
\0540
ess
A11 -0
a.
i Wr.LL l0VrlrLr.11VV4 L%LrVA1
DEPARTMENT OF 'HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
✓�
WELL LOCATION
STREET ADURESS: wNIVII ! 1 Y TAX GRID NU&IkR:
INDIAN HILL ROAD, PATTERSON, NEW YORK Lot 22
WELL OWNER
NAME: ADDRESS:
DAVID M. LEHTONEN, Brick Hill Rd., Lincolndale, NY
® PBIVATE
tO PUBLIC
USE OF WELL
1 - primary
2 - secondary
fR RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND.IHEAT PUMP ❑ ABANDONED
O ;BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
p ;INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
i 5 2 – 5
YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal..
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
j3NEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
' WELL DEPTH 545 ft-
STATIC WATER LEVEL 39 ft.
1 DATE MEASURED 10/9/91
DRILLING
EOUIPMENT
o ;ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
O ,WELL POINT O CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING 20 OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH 81 —ft.
MATERIALS: ..0 STEEL O PLASTIC O OTHER
LENGTH BELOW GRADE 80 ft.
JOINTS: ❑ WELDED - THREADED O OTHER
DIAMETER 6 in.
SEALxfl CEMENT GROUT O BENTONITE OOTHER
WEIGHT
PER FOOT 19 Ib-/ft.
DRIVE SHO&�aYES ❑ NO
I LINER: ❑ YES O NO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH (11)
DEPTH TO SCREEN (ft)
DEVELOPED?
-FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
o iYES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED j 1 tests were done is in-
,
XR COMPRESSEU AIR , formation attached?
O BAILED 0 OTHER i : ❑ YES 0 NO
Yy EL,L LOG 'If more detailed formation descriptions nr sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
WeII
Oia
In
FORMATION DESCRIPTION
CODE
It
It
WELL DEPTH
ft.
DURATION
hr- min.
DRAWOOWN
It,
YIELD
gpm.
Surface
20.
Soft sandy .gravel.
- 20
40
Gravel &.sand.
320
1
15
3.5
40
50
Gravel.
440
2
-
8
50
70
Soft bedrock.
545
6
-
9.5
70
75
Soft brown seam.
75
.545
Hard.grey & black granite.
WATER xf[l CLEAR TEMP.
QUALITY ❑ CLOUDY HARONESS
❑ COLORED ANALYZED? MES ONO
ANALYSIS ATTACHED? M YES O NO
STORAGE TANK: TYPE Diaphragm
CAPACITY $6 GAL. 23
WELL DRILLER NAME MILL DRILL I 18/9
ADDRESS Putnam Avenue SIG RE
Brewster, NY •
Robert M. Mill, President UA
PUMP INFORMATIO N '
TYPE suLmersible CAPACITY 10
MAKER G101 11 CIS DEPTH 500'.
MODEL 10E 15 VOLTAGE230 HP h—
S/ by
CHEMICAL
PHYSICAL
BIOLOGICAL
NAME AND
ADDRESS OF
PERSON TO
RECEIVE
REPORT
ELLIS A. TARLTON LABORATORY
DIVISION OF ELLIS A. TARLTON, ENGINEERS, INC.
34 PLEASANT STREET DANBURY, CONN. 06813 -2328
P.O. BOX 2328 203 - 748 =7903
WATER - WASTEWATER
METHODOLOGY
APHA - EPA - ASTM
REPORT OF BACTERIOLOGICAL AND CHEMICAL, EXAMINATION OF WATER
J.
F Mill Drillina Inc.
Putnam Ave.
I
Bre wst r NY 10509
l� J
DATA
SOURCE OF SAMPLE
Water Supply, Lebtonen
Indian Hill, Lot 22
Patterson, NY
DATE OF COLLECTION Q c t . 14 , 1991
COLLECTED BY Mill Drilling
Hydrogen Ion
COLOR
TURBIDITY
ODOR
CORROSION INDEX
DISSOLVED SOLIDS
Concentration
LANGELIER
(PM)
RYZNAR
NTU
Mg /:
Alkalinity as CaCO3
Fluoride (F)
Bicarbonate
Nitrite
Mg /L
Mg /L
Mg/
NITROGEN
Alkalinity as CaCO3
Chlorine Residual
Carbonate
CONSTITUENTS
Nitrate
Mp /L
Mg /L
.00 Mg/
AS.
'NITROGEN (N)
Total Hardness
as C -0O3
Conductivity
Ammonia
Mg/l.
Mg /L
Micromohos /n
Mg /L
Iron as Fe
Mg /L
Mg/
'Chlorides as CL
Mg/l.
Manganese as Mn
Mg /L
Mg/
Detergent as MBAS
Mg /L
Sulfate as SO4
Mg /L
Mg/
The arithmetic mean of all standard samples examined per month using the membrane fitter technique shall not exceed
one colony per 100ml. Collform colonies per standard sample shall not exceed 3/50m1, 4/100ml. 7/200m1, or 13 /600ml
in: (a) Two consecutive samples: (b) More then one standard sample when less than 20 are examined per month: or (e)
More than five per cent of the samples when 20 or more are examined per month.
AT THE'TIME THE SAMPLE WAS SUBMITTED:
1. The'results of the analysis of this sample were satisfactory and met requirements for a potable water,
MEMBRANE FILTER TEST
Collform Colonies /1100ML
0
2. The results of the analysis of this sample were satisfactory for a potable water but certain of the chemical or physical constituents were high. These are as follows:
3. This sample was not satisfactory since It did not meet the bacterial requirements for potable water. The presence of organisms of the coliform group In a sample of potable water is
undersirable and. while not necessarily indicating the presence of any disease - producing organisms, does indicate that such contamination might survive to the same extent. The
presence of organisms of the coliform group may also Indicate that the treatment was not adequate at the time the sample was collected.
4. This sample was unsatisfactory as a potable water because certain chemical or physical constituents were above acceptable limits. These are as follows:
COMMENTS
The bacterial analysis showed no organisms of the coliform group at the
time the sample was collected which. indicated the water potable.
: z� �
Carlified........................... ........................... :.........................................
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a cam, .e catMi amw, cc , ®4 >�m aa*ni nv i0m 4047 o t6b i 1" ®a � (a) V?a, +a OoROIy uolt7l ilita 4iasaa4®to of tia® Mal-
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Licorm No.—
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b Oa^y cam pP Rw ( o ov Fti4t3O mWon co y 'try 4 . cofaaionw of 6Cu]RW. Any eWoc or oiQP9a4�n of Colal4vaax4lmw
G V VC3 a a= - 6RIL . AC�7 C 1 Qov olN,�l of atoaat Rsl1 )to CratC77 c3opp0y only. ®�
Rev..
10/80 �o Oy Yi4b
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N. 1051? r Engineer to
i Division oi>�tvtienmental Health Services Carmel, N on CERTIFICATE OF C0
PIITNAM'COUNTY, DEPARTMENT OF HEAL
Permit q
k�,tCON„ IICTION PERMIT FOR SEWAGE DEPOSAL SYSTEM � Permtt N
Loca ted ,t pia -r�n� ` TI' l�l� -r�, 12 _ own
Sabdivbton Name "i'P i i Sabel. Let #, �Z Tfu Map Bloch
z 7z
M ail tZ o k 1-1 c� K s R �i
Renewal_ ❑ evblbn
Owneir /Applicaut Name Di ri1/�t. LU i?M S N 7 Ci0 ,
---
Date'ut Previous Approval
n
MaWng Address °p• .. �?) id !`j'.7 b. Town (i/�d M KttiL- ZIP
t
Btt g Type ` I2-", l !� ti iy fl �A-L Lot Area �'' ! FM Secdon Ohly LJ Depth Volume
i O .. PCHD NodBcedon Is Required. When FIU Is completed
Number of Bedrooms ' � Design Flow G P D ZD .
i
Separate Sewerage System to oiiasiet of �1 won,S-4tic Tank.en
to be oonetructed!hy:#oM2t?�r :l1 tS,�/,. L7%:. Address f ok q7T
wow,
Supply ParbUrs Supply From Address
n'
ort Private Supply Drilled by ILi. 1Ltl,tiiN ddeeee P0 7lV.r !vft_., /LPuyS1 2 . [v
Other it
eouliemente f% t Pih't�4° C•t 1 Y17/A =!/�l' 7� l2 t �l �'n
I represent thit•I am wholly •and completely responsibl,, for'the design and
above desciibed.will'be constructed as shown on'the.approved, amendment;;
County Department of Hq{Ith;' and thaton completion thereof a Certil
be 'submitted to. the' Department and a wntten'guarantea'.w,ll De' Turn
place an:good'operatinq, condition any part ot..seid sewage disposaf;sy
ance`of the�epprovat'of ther Certifieate,of Constructron:COmplMnce ' o
will be located as shoivn'on "the approved plan and ,that said well wrll t►e.,insl
County Department of 'Meiith.
7
Oats 7-� i ., Spned
!G
Address-
I' ,� °� rl�l /L'1�✓l
APPROVED FOR CONSTRCTION This approval exprresawo year' .f,
revocable for cause'or may be; amended or, modified when consider ne
requires a new permit.'' Approve 1 r disposal of_.domestic sun y
�7
BI Date / . — �i�i 'tJ A By
s); 1) that the
in accordance with the s
lstruction' Compliance'-'
nei,.hs iucceawf; hens
the' period..of .two (2) y
or any repairs t
irdance'A ith the and
V
I*ttory to the Commissioner of-Mealthwi11
ssipns by.the builder, that.sald builder will
mmediately following - the date Of the MY-
. h/� ; 2) t the'drilled well described above
ules d r u a onf of the Putnam
P E. 'R.A.
!2� ce se No 4'6124-
'the building has been undertaken and is
Any change or✓ alteration of const ruction
_ Title a+ ' '�•
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DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # �°
WELL LOCATION
Sttrree Address ` To V
-IV MOA 1f w
Tax Grid Number
0, V. 00 °2 °,7,6o I
WELL OWNER
Nam Mailin Address
9�. doh V_h P® a ®x
o
rivate
0Public
USE OF WELL
primary
2 - secondary
RESIDENTIAL 0PUBLIC SUPPLY
9BUSINESS O FARM
0 INDUSTRIAL O INSTITUTIONAL
OAIR /COND /HEAT PUMP
0 TEST /OBSERVATION
0 STAND -BY
0ABANDONED
0 OTHER (specify
AMOUNT OF USE
YIELD SOUGHT 6o O gpm /# PEOPLE SERVED a 4 /EST. OF DAILY USAGETOO dal
® REPLACE EXISTING SUPPLY 0 TEST /OBSERVATION 12-ADDITIONAL SUPPLY
MNEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
ae pt e
WELL TYPE
DRILLED
®DRIVEN
®DUG
®GRAVEL.
® OTHER
IS WELL SITE SUBJECT TO FLOODING? YES )< NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: HIZZ
r Lot No.
WATER WELL CONTRACTOR: Name .I 6 ��I Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _&_NO
NAHE OF PUBLIC WATER SUPPLY: A* TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: gip /44
LOCATION SKETCH & SOURCES OF CONTAMINATION P
KDN SEPARATE SHEET
(da e) (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 provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well dr operations be contained on this
property and in such a manner as not to degrade or
op
'se contaminate surface or groundwater.
Date of Issue: r �3 19��
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transfer able White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
N
F
1
c:
20 ii
1 �
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APPENDDC B
CCUNI"_' DERAR`IIM?r OF HEALTH - DIVISICN OF ENVIRCMMM HEALTH SERVICES
_ UIVT_.DUAL VATS
(�ame of Cwna'" )
SrT "Z-1 DISrUISAL SISTEMS
REV= Sir - CONS"M=ION PERMIT
(Street
ccr-11 S
YES
LAC
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..7 SYST� . IN IkWA
C-11 aVpar?-' er
10 ft.
I
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rle-q a
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ft. re e -voir, etc. Li
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DATE -- -NMp. : l l
�7 —
BY: C
Locatica)
Permit Application
, C- crporate Rescluticn '
Plans - Three s/s
Engineers Aut'horizaticn
Design Data She MCS) SUEDIV2 IC'i
Deep Role Log Perc
Consistent Perc Resat is (3) Fill
PS--c Hole Dept's cd _... --
Hcuse ;rpermt; - Two set
Well P" is letter
Variance Rerrues -
G
Legal Subdivision
Subdivision Approval Checked
Ex- =czrcval SSDS Ad-;. Lots Checka-_
Wet'-and (Tav-n/DEC Perrot R & D)
Data Cn DDS Plans & Permit samE
REQUJURED DEM=TT c CN pT.] .
Sewage Systr1n P'_an -/ nart3 a=,;w
S =.v%Ce SY5%�T1 i1VCralL _ ,L_ 1 °_ - Ci.'_v4 t.7
Fill- Profile & Dimens_cns - V,-j- =7S
D or J Eox;Trencn /C :'lery; _P=te pi ils
SCpric Tank - Size, Der,: it
Well Detail, Service Line if cver
Ccnstructicn Notes (cringer rte)
Design Data: perc and deep reszl _s
Tw-a -Foot Contours Existing & P_opcsed
Drivevy & Slopes Cut
Foctincr/Gatter,Curtaln Drains (discharge CK)
Perc & Deep Holes Loc=ated
Representative or primary and ex..ansicn
Expansion Area;shcran;gravity flcw,ssff..size
If P,i Pit & D Box Shen & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in .200 ft. or Proposed Systa-
Prope_ -ty Metes & Bounds
House Stack Necessary (Tight lot)
House Serer - 1 /4 " /ft. 4 "0; T_rpe pipe
No Finds; Ma=c. Bends 45° w /cleancut
SE R=0N DISTANCES SPECIFED C:i PLAN
Fields
10' to P . L. , Driveway, large T= aes, Tcp of f
20' to Foundation Walls
100" to Well; 200' in D.L.0.0, 150' pits
100' to Stream, Watercourse, L=ice (inc. et--c
15' to Drains-Curtain, Leader, Footing
35'to =tch basin, storindrain,ciced wate_r=Ur
10' to Water Line (pits -20')
50' ' te_nnittent drair-aQe ccurse
Sectic Tanks
10' frcn Foundation; 50' to well
15' Well to PL 9
Patnam County Department of Health
Division.of Environmental Sanitation
AFFIDAVIT CORPORATE OWNER APPLICATION
FOR PERMIT: APPLICATION SUBMITTED TO -
PUTNAM COUN.TX }IEALTH DEPARTMENT,
Tb< Commissioner. of Health •- In the matter of application for `
Awo& Ifc- (6-± 5
. . �e -T � Ae • ae° P
I9 � if 12- L lc? C C%ol:::�<. �. — — — — — —...- o represent
that I am an officer or employee of the corporation and affi authorlied
DCt® act for �QAe I11jfAT
.(name of corporation)
having offices at Y�� (— �v_1�� �— 4_p �by
4 .— �..1 02 — — _ — ` Whose- officers are
President
Q �,L �,��4�S7E�
lame anT address)
Vice - President �� (J j�} CIO Ct�t,,to G�Q�� �Jt�
— — — (Name and Address) =
Secretary `�v J� — CLo CGO 4- i�vl71 — _ G 2 '� ®al
—
(Name and Address) .
Treasurer _ _
---- - - -— (Name. and Address) -- --- - --
and that I am and will be individually responsible for any or all, acts
of the corporation with -respect to the approval r quested and all - sub-
seque" t act9 relating . thereto o
Sworn to before me this /;� day Signed _ m m of 1987 Title L ZA-.-f-
'90tary Public
ANNE B. COhR10AN
C�reC "
ftA a9 0
. RB!i a g6nyd
�488 3�
d j
U) .a
Y_
0
Corporate. Seal
9
i
i
TWO COUNTY
DEPARTMENT OF HEALTH
Division of Environmental Health Services
CENTER - CARMEL, N.Y.. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Street Address Town Tax .Grid
rjoZM -'v A4 Al it ..rte -t a_v . Fig Tit S -a U N
Number
o - 2-- 2-&, 1
WELL OWNER
, Name Mailing Address
IVIDOV4iL 6,16047 L4 Y C,6,
p � cl�r
Ur Q, G ,6•L_ rj
Private
5 °YL 13Public
USE OF WELL
a - primary
2 - secondary
� RESIDENTIAL O PUBLIC SUPPLY
13 BUSINESS O FARM
'0 INDUSTRIAL O INSTITUTIONAL
O AIR /COND /HEAT PUMP
0 TEST /OBSERVATION
O STAND -BY
D ABANDONED
0 OTHER (specify
p
AMOUNT OF USE
YIELD SOUGHT '5,0 gpm /# PEOPLE
SERVED Q--(, /EST. OF DAILY USAGE Mt gal
REASON FOR
DRILLING
EW SUPPLY O PROVIDE ADDITIONAL SUPPLY
! OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL
O TEST OBSERVATION
DETAILED
REASON FOR
DRILLING
PtMO (2 1 t�YzN G
WELL TYPE
®DRILLED 13
DRIVEN
E]DUG
O
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING ?, YES
_NO
IF WELL IS LOCATED °IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No. _Z�Z.
WATER WELL CONTRACTOR: Name rrb (?% pp�°Z/z,tZsVl wi Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _Y NO
NAME OF PUBLIC WATER SUPPLY: tdlA- TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: N1A-
LOCATION SKETCH &'SOURCES OF CONTAMINATION PROVIDE�LOON L-2-1
O ON!REAR OF THIS. APPLICATION SEPAx4E SH T
(date) OTS ignature)
i 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
the applicant shall:
1. Pump the well until the water. is
2. Disinfect the well in accordance
County Health Department attache d
to this pe it.
3. Submit a Well Completion Report
Health Depart ent.
Date of Issue: 19 0 0
Date of Expiration: 191
Permit is Non - Transferrable
9
completion of water well construction,
clear.
with the req irements of the Putnam
on a form pr vide by je P4tngq County
Pemit Issuing Utticial
White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
Orange copy: Well Driller
Ran
i i Elapse
Ti.M
Start:-Sto p Min.
.:Depth to Water From
'Ground Surface -
Start stop
Inches
Water Level
In "Inches
Drop In
-Inches',.-
"J--Soil Rate.
Min,/In 11FCP
2
�AO,C
10/ ( -
4
3
4
5
NOM: 1. Tests to be repeate(I at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to'be submittlad
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85 -
2
2-7
4
3
4
5
NOM: 1. Tests to be repeate(I at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to'be submittlad
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85 -
U un • u • W • !1• &Is? Us Is _ _ a '..J IB! : - -.
Name (-A-U a4wr fi-PGr.A,° ev67- Arree, Signature
LU
Address `73- SEAL
N .-'124
0r FSlti�5?v.�d
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY.*
Soil bate Approved sgaft/galo Checked by Date
• is
..... SEKViCES- = I ::: DIVISION :OF: iEZITH _
RESIGN DATA SLUM - SUBSUFACE SEWAGE DISPEL SYSTEM : FJI,E NJ::` -
21
-•
Owner'°b:/o�pM
N�a r� k �,7 20
:.. ,
Located at {Street)' 6OG `Gci Zacv, 2a A'jj ,�.:• :` _ ..,.Block �, :;! — Lot . UP��
(indicate nearest cross street �'
-"
Muriics 5ality, ; M W N �P}7Z nSc n1 Watershed
C.M • ' 0 nj ,
SOIL, PER03LATI0NT DATA TO BE WITS APPLICATIONS
- ........... .._:. .. ._[+..... r:.a/...t4.•...J. •.__wry.. r.iw pS..- iN.l..._.:::�
Date of Pre- Soaking l0 1.3. Date of Percolation
y
•. •T•♦
`ice 3 S7
.Test
4 .
NiP�iBER QOCR TIME PER( OMMON : -__.. -_ _ .
_:.__. _ PEItbOLATION
Run ! Elapse ,.. Depth to Water From ' Water Level
;
No. _ = Tines - Ground Surface: In = Inches
1 :.Soil Rate T
Start Stop 1M1I1. ._. , Start Stop :.. Drop In
Clo . _., ... ...: .. Inches . finches ..__inches - ...
p
_... Minfln Drop; ::
..
NOTFS: 1. Tests to be repeatel' at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to' be subnitt,14
for review.
2. Depth reasurements to be made from top of hole.
rev. 9/85
i
21
-•
�
2 h;'1L - (x:43
2 ?"
2,.
••
3 ..... ..
.
3 -6"44=' i7 : ( 4
; •30
4 .
......
G loa
2
29
T
{
2
i
NOTFS: 1. Tests to be repeatel' at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to' be subnitt,14
for review.
2. Depth reasurements to be made from top of hole.
rev. 9/85
i
No. of Dedroans Septic Tank Capacity - 116—b gals. %We • CRAIG
Absor t.On Area Provided By L.F. x • 400 W1dt$b trench
Other 7 ` ' D�_; � &0a_7-A(A) D tz,+//J alli ul r,,Kv
�G y.
Name L" ag-Nr Ii_N 4 i,4) a /Jeoc, Pe_ Signature
-Address 7 3 r—AI Kt-Mt,0 0 h-11 vt_I_ SEAL
�:'� •c ~fit
�p i7i1� 3 No.
�—° -�-_ ARO F c `OP, ter'
THIS SPACE FOR USE BY EEALTti DEPARTMEW ONLY:
Soil late Approved sq.ft/gal. Checked by Date
I�iv l t --T
t%IM>iN1�1O� ---HAiZ7
N °
A
i3
I
12.di!
22'
to
23'
73'
1 I
2q'
b 1
12
35'
8q'
13
�I'
87.5
15
53'
X14'
:Xoq- weu
/O
THIS IS TO 'CE2TWY THAT THE SEWAGE✓ DI5PDSAL.-
ele
1.0
1,200 GAI-
�iEp11G TANK
Z' 3
a y
v
t�
A
r
THIS IS TO 'CE2TWY THAT THE SEWAGE✓ DI5PDSAL.-
ele
1.0
1,200 GAI-
�iEp11G TANK
Z' 3
a y
v