Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1761
DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -100 BOX 16 01761 ko%. ..' r I '. 01761 AM COUNTY DEPARTMENT OF HEALTB - MMON :_ :OF-ENVIRONMENTAL,WALTH SERVI1 CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT PCHD CONSTRUCTION PERMIT # F- X51+ 0,11, Located at e)d A f y H n' L_ �0)k® Owner /Applicant Name `i ' ' N0 i 14,q Formerly Town or Village Tax Map Ph, � 0 PAIM 6©H Block 4 Lot 100 Subdivision Name pEfp boo Subd. Lot # 0 r t OMailing Address "e Date Construction Permit Issued by PCHD ✓ Separate Sewerage System built by 100kft L IAOMO INC- -Address I� ULL%�`4' ,0k) DPpi A' Ok iti Consisting of i �. �0 Gallon Septic Tank and 0 �' �,(vJ C 1 iv/ I� i• �t Other Requirements: Water Sup&: Public Supply From Address or: Private Supply Drilled by $Gi9 K' Kw LL ° Address M-4 Pr -"72, 6"& f4it$71t 0� WC � Has erogron oentrol been com leted`� ..........��- _ - - e p Number of Bedrooms Has garbage grinder been installed? I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and. approved plans and the standards, rules and regulati* Js of the Putnam County *partment of Health. Date: Address Certified by �� , P.E. )( R.A. n rr."zWo mu r S � tJ 1 10 4 © 1 License # 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 separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void. when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocat'on, modificati n or change is necessary. By: M Title: Date: '' White copy - HD F le; Ye copy - Building Inspector; Pink copy -Own , Or copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT v Wel1'I;oca- ibn' = 'Street Address: /LZ- Towh/Village Tax Grid # Maps 61 Block ' Lot(s) F 0 Well Owner: Nam d: Address: G�1 a1 ' ; Use of Well: 1- primary 2- secondary _X_ Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Well Type Rotary Cable percussion _ Compressed air percussion Other (specify) Screened Open end. casing X Open hole in bedrock Other Casing Details Total length ft. Length below grade YVft. Diameter _in. Weight per foot lb /ft. Materials: 4 Steel _ Plastic _ Other Joints: Welded X' Threaded _ Other Seal: X Cement grout _ Bentonite _ Other Drive shoe: Yes No Liner: Yes _l No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _Pumped Compressed Air Hours Yield , gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet i Well Formation Diameter(in) Description Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing ft. ft. Land Surface ° f If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Igo ,y Pump Type CapacityJ& Depth Model Voltage 1A.0 HP 1 Tank Type W 2 Volume t� Date Well Completed Putnam County Certification No. Date of Re ort Well Driller (signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be provt on a separate sneevptan. Well Driller's Name j Address: G� Signature: Date: !/ 3 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; orange copy - Well driller Form WC -97 November 10, 2004 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Fax: (845) 279 -4567 Email: hnengineer @aol.com Re: Individual SSTS Compliance - Windsor Woods Subdivision, Lot # 8 80 Apple Hill Road Patterson, NY Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing S-8, "As -Built SSTS," dated 11/10/04. 2. "Certificate .of_.Construction Compliance for Sewage Treatment System,.' -- 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System," dated 11/10/04. 4. Laboratory Report, dated 10/15/04. 5. "Well Completion Report," dated 11/03/04. 6. Application Fee in the amount of $300.00 payable to Putnam County Health Department. 7. E911 Address Verification Form, dated 11/10/04. If there are any questions concerning the enclosed, please call. Very truly yours, Harry .W. Ni Is Jr., P.E. HWN:gav 03- 056.08n - BRUCE R. FOLEY ti �. LORETTA MOLINARI• R.N., M.S,N. Public .11011h Dlrccloro • - _ ltuoclatt Pub(lG ;.Hta11h .Witcror„ _ Dfrtcfor- Q/ Pailrnl Str vkcl s -��DEPARTMEIP OF "HEALTH . w... a.. :. _ .. -.. �_...... - 1 Gcncva - Road - _ Browstcr, New York *10509 I;&*OOMCAitl Ballh (914)271 -6130 Ftx(914) 271 -7921 Kurthl. Stn(ca 4w) 271.4518 -•• WIC (914}17t--6671 •M (m) 271- 6015 -- ` • Ltrly'7otcniotToo- (914)17f -6014 Praclool (914)2114012 F4x(914)27f -6641 F2LADDRESS `VRYFICATION FO RM _. OWNERS NAME: { " Ji, E911 ADDnSSI.. �v w)' Ns PGA ► I- r�►rit �U l- i AUTHORIZED TQWN_OFMCTAL: . (Signaturc) DATE: _.. The Putnam County Department of Health will not issue a Certificate of .ConstructI n Compli.ance-unlessAhe above; form is. completed * -i:e.,'a IegaTE911 address is assigned by an authorized town official. This form is to be submitted""-• — with the application for it Certificate of Construction Compliauce. TAW (E911 VERnUA)- . ,... .... _ E506 LE02 LE 02 95 T 6 6ET6 TO 1.6 SOOT -paqSaWS.ST .- wnTpoS Ao I/% OLE jo wnwTxew e KaTp pa4DTjqsaj AXWWPOU) w uo asoq• Jo" WnTpos go I/Bw 02 uwqJ ajow Ou UTUquon pinoqs jaqvm aqq6qajp paqnjjqsaj wnTpas u uo a1doad joy qeqq aqeqs saullapTn5 palsaWS -paqTinsaid aje wn1paS joy sqTw;l ON pr-11 -I/BW g-O paamxa qou 11eqs PauTqwo:_-1 anjeA jejOl JTaqq QUaSeld SWW W•UeWeW pUe U•WT qqoq 1I UW/8...-.1 ,1eTquaqod aATSOjJOM sjaqwm sqq amnpaj ol uaNeqjapun aq qspw quawqeaj4 jaqem asTa '1/5w E-1 jo anlWA H3ddoo e PUe qdd q1 Ueqq. ajow jo anIOA UVEJ W aAWq SqUjOd uoTqnqTj4sTp jTaqq go %01 ueqq amw ou •uqq sajInbaj swaqsAS mllqnd joy alnU jaddoo T Peal Vd3 "qdd q1 qp :: ?as aje sycoqn• nTlqnd _too sqlw;l uw3• no /c ,j NO11331700 AO 3WII 3HI IV WI WI SUE13WVAVd 3H.!. MOO 'SUMVUNWIS U1IWM SNIANIOU !WWWW Vd3 UNV 31WIS NAOA AHVIINVS AUDIOWAS11US. V AO UON 'ES M) -k13IUM 3HI IWHI mumaNI SIlnS3M 3S 3H1 13W-1 F1114 C;_C) V /14 WIN Y/5w 11bw E'0-0 V/ N OT - 0 qdd gT.() IN38OW n I N D 1/ sw 0"25 I/ sw BET SI1Nn sm 1/ sw 7 "91 1/ sw 01OW I/ sw 090"0> I/Sw To"O> WOW 90"L qdd I 1W OOT/ IN3SSW mm) Alluismni SU) AWN11WAIV 1VIOI'SSaNU2JVH Hd (UN) wniuos (UW) 3S3NVDNVW (00 NOW 0081IN alIMUN DOWN alUM11N . 4swi) uVal WHDAI103 11 AW 311JOW 10/80101: 50/ GO/ 0 T to/ SO/ 0 T 50/ SO/ 0 T to/ ebl o i: 50/ BO/ 0 T to/80/01: to/ SO/ 0 T 50/80/0'f 90/80/OT 90/80/OT AIND WUNim amnamoud gum 11011 --------------- m -------------------- -------- m-m --------- - AW AHIAW WHO11103 018 3SOH,9 ... S310NI in > u,"mmumms-L NAG 0103 3NON 1S3A11VAH3SA%J AN NOSNAilUd UH 111H niddW A t 31010d l - - WAI 3!d•VSi smaw i4maium s im QIIS SNI!dWV'3 2202 50/91/OT VOTIOT 50/80 /OT VOT160 50/90/01 -WWWNS) h3N00.::1 031vu ImOd3H NaWBU 3WII/31011 NN3NUI 3w1I/3IwC_'f 60901 AN "WISM3% WHU UOOMNI1103 f-.3 S_]WOH WVI-KINAM -------------- m ----------- 7 ------------ ---------------- m ------ m --- mm ------ m--,. Usud 30AJ IVIS NON WIL9 3# IN3113 29E20b"E6 1# OW-1 JOqDaJTU 'TUMOped -H qJaqlV S6901 'A"N "HOTaH UMUNJOIk 4ealls isom i2E S331AH3S IVIN3WNOHIAN3 WA YML ENVIRONMENTAL SERVICES ^ 321 Kear Street , Yorktown Height,, N.Y. 10503 (914T'245z2800! Albert H. Padovani, Director LAB #: 93.402352 CLIENT #: 57197 NON STAT PROC PAGE: 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLINWOOD DRIVE BREWSTER, NY 10509 DATE/TIME TAKEN: 10/08/04 09:15A DATE/TIME REC'D: 10/08/04 10:10A REPORT DATE: 10115104 PHONE: (845)-279-2022 SAMPLING SITE: LOT 8 WYNDHAM HOMES SAMPLE TYPE..: POTABLE : 80 APPLE HILL RD PATTERSON NY PRESERVATIVES: NONE COL'D BY: TEMPERATURE..: < 4C NOTES...: HOSE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ BIB ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY, WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEFENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 MG/L MG/L-= MILLIGRAM PER LITER '-'^ '44 grata/ | SUBMITTED BY: Albert N Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF. HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICE:$ 4 GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM DO Owner or Purchaser of Building Tax Map Block Lot Building Constructed by Location - Street TownNillage p6r�-g wvv p Subdivision Name Building Type.' Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and "drainage of the sewagelreatment system serving tlie'above- described' property, and that is 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 parr-of said ` 9ystem constructed by, me which fails) to operate for a period of two years immediate) following the date of approval of the "Certificate of Construction Compliance" for the Y g PP P sewage treatment 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 Public Health Director 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.. ;eneral ed: M j� Day �r� Year Signature: 1.10 C' BIT. r -r Title: Contractor (Owner) = signature y Corporation Name (if corporation) Address: ��l.Llt� Q� -� �ATf4joo State Mfg Zip Corporation Name (if corporation) Address: ' M0 00- State �i�i Zip to Oq Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH I! g /o 1/ - 0/' ,r DIVISION OF ENVIRONMENTAL HEALTH SERVICES 4 ` ° FINAL SITE INSPECTION 9�1 � ��� Date: 41X7109 Inspected by: Street.Location _ S U Owner AI XIVO A14- AGA65., Town oX1 Permit # p -- 3 g - o 3 TM # -3!S- — 9 — /o Subdivision Lot # 8 1. Sewage System Area 11YES NO COMMENTS a. STS area located as per approved plans .......... .. ................ k- b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... k7� e. 100' from water course / wetlands ...... ............................... II. Sewage System" a. Septic tank size - 1,000 111:1. .1,250 .......other..." b. ' Septic tank installed level..... ........................................... c. 10' minimum from foundation .......... .........1...11...1............ d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ....:.......................... 3. .. Nfinimum 2 ft. Original soil between box & trenches e. Junction Box properly set .......... ............................... 6. Trenches 1. Length required So o Length installed 5-e7zn, 2. Distance to watercourse measured -- <o a Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - llk" diameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... 10.. Pipe ends capped ........................ .... ..... ........................ g. Ttimp dFD6sed ,*'steins _ _. - - -. • - - __. _ 1. Size of pump chamber ................. ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual / audio ........ :.......................................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... HL House/Builditig a fs a. house located per approved plans.... .Y9..' .... "P. �pP b. Number ofbedpooms .................... .. f?P ••le IV. Well Well located as per approved plans . ......:........................ P. Distance from STS area measured ft........... c. Casing. 18" above grade ................ ............. ................. d. Surface drainage around well acceptable ....................... V. Overall Workmanship . Qpt u/ a.. Boxes properly grouted ......................... ` b. All pipes partially backfilled....... , , [LG .......... .. . 1111... c. All pipes flush with inside of b rL; i'' '�` t.. � ,..r y,� e. —u rtarn arain & stanapipes stku mg E 4 f. Curtain drain outfall protect into exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water Rev. 1210 protection adequate ........ :........................... i. Erosion control pro2 vided ................. ............................... AUG-26-2004 01:01 PM HARPY W NICHOLS 914 279 4567 P.01 L) 0 PUTNAM COUNTY DEPARTMENT OF HEALTH DM- SION OF ENVIRONMENTAL HEALTH SERVICES U!QMSI EQR FTN im For: Fill* Date: Trenches — 7 PCRD Construction Permit Located:- (T) M Owrier/Applic,-mt Name: TM_'MZ_ Block Lot 106 JFormerly: Subdivision Subdivision Lot ls'system fill completed? Date. fs system complete? 1 plete? Is system constructed as per plans? Is well drilled? Is well located as per plans? Are erosion control measures in place? Date', I certify.that the system(s), as listed, at the above premises has been constructed and I have inspected and wrifed, their completion in 'accordance with the issued PCHD Construction Peardt and. approved plans and the - Standards, Rules and Regulations 6f the Putnam County. Department of Health. Daee Certified 'by: Pro Wessional L Address: Lic. # comraetqs:. FOR: 0 ADAM CM le- 0,7 _0,71.71,1 _rLJ1 I -1 .1 Form FIR-99 v 1 r y+.,e LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 August 30, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI . County Executive Re: Field Inspection — Wyndham Homes Inc. Apple Hill Road, (T) Patterson Lot # 8, TM# 35.-4 -100, Permit # P -38 -03 The following comments must be addressed. 1. Remove all rocks (i.e. < 4 inches in diameter) from backfill material. 2. Add cleanout between septic tank and system (required every 50 feet). If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. GDR: cj Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide L' -" LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 September 2, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Field Inspection — Wyndham Homes Inc. Apple Hill Road, (T) Patterson Lot # 8, TM # 35. -1 -100, Permit # P -38 -03 The following comments must be addressed: Per My comment letter dated August 30, 2004, after careful consideration of the large - - arnou4 of- rock.'exeavated.from -the SSTS area it has.been -a growing oGncern.tlia the - -. operation of the septic system may be jeopardized due to shallow ledge or fractured ledge rock. Therefore this Department is requesting deep test holes in the SSTS area in order to ensure the proper function of the system. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. Sincerely, i� 0 —o?e-Zw Gene D. Reed SR. Environmental Health Engineering Aide GDR:km SENDING CONFIRMATION DATE SEP -2 -2004 THU 15:34 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES : 1�1 START TIME : SEP -02 15:33 ELAPSED TIME : 00'41" MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... a LOREITA MOL NARI ROBERT 1. BONDI P08a H.118 Oe— Coney 6 —t. DEPARTMENT OF HEALTH 1 Geneva Road, Browster, New York 10509 BeNronmeaal ne 1M (843)178.6130 F"("37B -7931 N-d g S rA— (843)278 -6598 WfC (845)278-6678 F"(845)278.6085 . aniy Inter daw?raeaool (845) 278.6014 Pax (845) 278.6648 September 2, 2004 . Harry Vic)1o1 , PE Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Ro: . Field Inspection —Wyndham Homes Inc. Apple Hill Road, (T) Patterson 14.t.# S. TM # 35.-1-100, Permit # P -38 -03 Dear Mr. Nichols: The following comments must be addressed: Per My comment letter dated August 30, 2004, after cardW consideration of the large amount of rock excavated from the SETS area it has been a growing concern that the operation of the septic system may be jwpardi2zd due to shallow ledge or fractured ledge rock. Therefore this Department is requesting deep test holes in the SSTS area in order to ensure the proper function of the system. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. Sincerely, n /. —024 Geno D. Reed SR. Environmental Health Engineering Aide GDR:km PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMEENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: STREET LOCATION: REVIEWED BY: RK GR. AS, SRDATE: TAX MAP #: (CONFIRMED) Y N DOCUMENTS Y �i (REQUIRED DETAILS ON PLANS CONT'Dl (7�i )PERMIT APPLICATION (/_)HOUSE SEWER -1/," FT. 4 "0'; TYPE PIPE CAST IRON f WELL PERMIT OR PWS LETTER ((_)NO BENDS; MAX BENDS 45° W /CLEANOUT PC -97 RENEWALS (_) LETTER OF AUTHORIZATION Ce _)SITE NOTE (NO CHANGE) (DESIGN DATA SHEET (DDS) FILL SYSTEMS CORPORATE RESOLUTION 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE [)SHORT EAF FILL SPECS/ FILL NOTES 1 -5 PLANS -THREE SETS (� FILL PROFILE &DIMENSIONS (__)HOUSE PLANS -TWO SETS (-DFILL IN EXPANSION AREA (_)L�VARIANCE REQUEST FILL GREATER THAIV 2 FEET SUBDIVISION CLAY BARRIER �r (LEGAL SUBDIVISION FILL CERTIFICATION NOTE (_)SUBDIVISION APPRO CHECKED (_) DEPTH GAUGES r PERC RATE � (�) VOL. ON PLAN FOR R.O.B. UNCLASSIFIED &IMPERVIOUS FILL REQ D -DEPTH �°' (_) SEPARATION DISTANCE FROM TOE OF SLOPE _)(_JCURTAIN DRAIN REQUIRED TRENCH GENERAL WL—) ` LF TRENCH PROVIDED 60FT MAX. LOCATED IN NYC WATERSHED PARALLEL TO CONTOURS �)(- PLANS SUBMITTED TO DEP 100% EXPANSION PROVIDED AaEEGATED L, PCRE (/ - )DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL APPROVAL, IF OBSERVED �GEOTEXTILE COVER P TEST HOLES OBSERVED SEPARATION DISTANCES ON PLAN - FROM SSTS P CS TO BE WITNESSED 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL X- APPROVAL SSDS ADJ, LOTS 20' TO FOUNDATION WALLS (WETLANDS (TOWN/DEC PERMIT REQ'D ?) , 100 TO WELL, 200 IN DLOD,150 TO PITS ( � DATA 69 DDS PLANS &PERMIT SAME 0100' TO STREAM, WATERCOURSE, LAKE (inc. eapan) (UU "PRE 1969 NEIGHBOR NOTIFICATION 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER LETTER BUZBA 10' TO WATER LINE (pits - 20') _._._.(_: _.__ WOYR. -FLOOD ALEVATIONW4200' (__)50'INTERMITTENT DRAINAGE COURSE (_)SOIL TESTING LOTS >10 YEARS OLD LY(__)IO'MIN 0200' /500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS REOUIltED DETAILS ON PLANS TO LEDGE OUTCROP SEWAGE SYSTEM PLAN - (NORTH ARROW) SEPTIC TANK SSDS HYDRAULIC PROFILE (�l.__)10' FROM FOUNDATION; 50' TO WELL GRAVITY FLOW WELL (CONSTRUCTION NOTES 1 -15 (_)DIMENSIONS TO PROPERTY LINES DESIGN DATA: PERC & DEEP RESULTS LOCATION OF SERVICE CONNECTION T CONTOURS EXISTING & PROPOSED 15' TO PROPERTY LINE )DRIVEWAY & SLOPES, CUT SLOPE FOOTING /GUTTER/CURTAIN DRAINS SLOPE IN SSTS AREA (S20 %) (_) USDA SOIL TYPE BOUNDARIES REGRADED TO 15 %, IF REQUIRED BLOCK; OWNERS NAME ADDRESS TM #, PE/RA; NAME, ADDRESS, PHONE# DOSE/PUMP SYSTEMS ( )DATE OF DRAWING/REVISION PUMP NOTES DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED L�DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS (--) DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) LAKES,WETLANDS WITHIN 200' OF P.L. U PIT AND D -BOX SHOWN & DETAILED (_l�(_)PROPOSED FINISH FLOOR AND U 1 DAY STORAGE ABOVE ALARM BASEMENT ELEVATIONS CURTAIN DRAIN ( /)f�WELLS & SSDS'S W/IN 200' OF SSTS STANDPIPES, 5' BOTH SIDES, DETAIL PROPERTY METES &BOUNDS 110'MIN 15' MIN to CDS = >5 %, 20' -4 %, 25' -3 %, 35' -1 %, 100 % -<1% (EROSION CONTROL FOR HOUSE WELL & 20' MIN to CD DISCHARGE /100' with 182 cons day discharge SSTS, EROSION CONTROL NOTE to NON - PERFORATED PIPE COMMENTS: (REVSHEET)09 /01 /00 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 e. • 2050 Route 22 Brewster, NY 10509 8k%2 Fax(845)279-4567 November 25, 2003 Putnam County Health Department One Geneva Road Brewster, New York 10509 ATT: Robert Morris, P.E. Re: Individual SSTS Deerwood Subdivision - Lot # 8 80 Apple Hill Road Town of Patterson T.M. # 35.4-100 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of SS -8, "Proposed SSTS ", dated 11/25/03. 2. "Short EAF ", dated 11/25/03. 3. "Application for Approval of Plans for a Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System, ", dated 11/25/03. _ S r._a _ "Application.to Coristruct-a W..ater ;Well "- hated: 1.1 /2:/03. _,...__._.______.. ..._....r .� �..•� 6. "Design Data Sheet ". 7. "Letter of Authorization & Corporate Resolution ", dated 11/25/03. 8. Two (2) copies of Residence Floor Plan(s), f r "Bedroom Count Only". 9. Review Fee in the amount of $300.00. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W. Nichols Jr., P.E. HWN:gav 03- 056.08 14 =16 -4 (9195) —Text 12 PROJECT I.D. NUMBER 617.20 SEQR Appendix C State Environmental Quality.Review. SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (ro be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR kAf�14PH�4A 2• PROJECT NAME r r Q 3. PROJECT LOCATION: T n P- H N -NA 1 Municipality r County 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) s17PPt. 5. IS PROPOSED ACTION: New ❑ Expansion ❑ Modlllcation/aiteratlon 6. DESCRIBE PROJECT BRIEFLY: tHDty ►u►�t1_ �ST� � W��t- � ��-' tv� W� 7. AMOUNT OF LAND AFFECTED: 2-10V) �' Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? I�Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? MResidentlal ❑ Industrial ❑ Commercial ❑ Agriculture Park/Forest/Open space ❑ Other Describe: �jlHlal� �k1'1t1,� 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes JKNo If yes, list agency(s) and permlllapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID. PERMIT OR APPROVAL? ❑ Yes 9No If yes, list agency name and permitlapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING. PERMIT /APPROVAL REQUIRE MODIFICATION? ❑Yes No. CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE RAW w ` H i wo%�6 � � � � � � I �5 � Vq ApplicanUsponsor na e: Date:. Signature: If the action is in the Coastal Area, and you are a. state agency, complete the . Coastal Assessment Fdrm'before proceeding with. this assessment 1 ' II PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD, IN 6 NYCRR, PART 617.4? If yes, coordinate, the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may, be. sup.erseded. by- another,invclyed.agAnpy.,,:l, - ❑Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise• levels, existing traffic patterns, solid waste production or. disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species; significant habitats, or threatened or endangered species? Explain briefly: C) r-• C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural r urce :Explain briefly C-4 t - 05. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly, 4,,D - C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly.�h •W 4�n C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TOE POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? i__..., ❑.Yes .. ❑.Na.- ,_.lf..Yes,- explain briefly...._ . ..:... -.... _...�...�.__.__..__.. _..._....•.. ..,.., _.:. ,.<_ PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For.each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) .probability. of occurring -.(c). duration; (d) irreversibility; (e) geographic scope; and (f) magnitude: If necessary; add attachments or reference supporting m%r)als: Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. if question D of Part II was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration. ❑ Check this -box if ,you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Print or Type Name of Responsible Officer in Lead Agency. Signature o Responsi le Of irer.in Lead Agency Name of Lead Agency 2 Title of Responsible Officer Signature of Preparer(if different from responsible officer) ..PUTNAM COUNTY DEPARTMENT OF-HEALTH T -. DIVISIO"F ENVIRONMENTAL- HEALTH•.SERVICES`' APPLICATION FOR APPROVAL OF PLANS FOR .... w.._..a..�..., .... . fi�V S I`EVVATFR'Y'RIEAT1i 1ENj1- -SYSTiEMI : - r :�JND�A�N1 -�t4ft� �. IH(,. 1. Name and address of applicant: .9-+ Ap bopgis 2. Name of project: $� 3. Location `I'/ViEpr 4..Design Professional: RA!`t`°t W* 0`Ut%L6 JQ4 5. Address: f�-0S(� -�� RO O ©o 6-. Drainage Basin: � — . 7. Type of Prp ect: Pnvate/Resi dent ial Food Service Commercial - Apartments.' - Institutional Mobile Home-Park.' ome - Park . Office Building Realty Subdivision __ . Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)?' ...: Type-Status (check one):... .................. . ............................... Type I Exempt Type II Urilisted- 5 X 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... �Jo. 10. Has DEIS been completed and found acceptable by Lead Agency? . . . . .. OA 1 l ._- Name of Lead Agency - - - tj A 12; Is this. project in an.ar.ea under the control of local planning, zoning, or other %_._ officials, ordinances? ..::. ::.:.::..:..................... .....:..... _.. _ 13. If so, have plans been submitted to such authorities? ....................................... IJO . 14. Has 'preliminary. approval been granted by such authorities? NA Date granted: 15: Type of Sewage Treatment- System Discharge....; ............. surface water" X "groundwater 16. If surface water discharge; what is the stream class designation? .................... 17. Waters index number (surface) ............................................. ............................... . 4 1.8. Is project located near a public water supply system? ....... ............:.................. 19.- If yes, name of water supply Distance'to wa-mr: supply A 20: Is .project site near a public sewage collection or treatment system? ::....:....::..:. �tQ 2 i . Name of sewage- system I`l Distance;to .sewage 'system' - 22. Date test -holes observed 23. Name of Health Inspector M11WR 24. Project design- -flow (gallons .per day) .............. ............................... � - -� �. �.::.$..�... _ 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.... - NA 26. Has SPDES Application been submitted to local DEC office? ......................... Form PC -97 2 27: Is any portion: of this prcj.eQt located within a designated Town or State wetland? . 28. Wetlands .ID.Number ............... ......... . ........................................ ................. ........ ,1��� '0 U+nrL 29. Js Wetlands Permit required?.....: ............:........... .......:........ ...............: ... ... No Has application been made to Town or Local DEC office? ....... ........................ 30. Does project require a DEC Stream Disturbance.-Permit? .. ............................... t1 31. Is or was project site used for agricultural activity 'involving application of pesticides to orchards or other crops, solid or hazardous - waste disposal, Iandfilling, sludge application or industrial activity? ............................ Yes/No ® 32. Is project located within 1,000 feet. of existing or abandoned landfill, hazardous maste site, salt stockpile, landfill, sludge disposal site or any b _CA other potentially known source of contamination? ................................ Yes/No tV U DESCRIBE: 33. Is there a local master plan on.file with the Town or Village? .......:................. f 34.. Are community water and/or sewer facilities.planned to be developedWithin 15 years in or adjacent to project site? ................................ ............................... �1 35. Are any sewage treatment areas in excess of 15% slope? . ..........................:.... tJ� Map ID Number ...... :...... :....... :.... Map ^��� Block 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall he.sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP _ —approval of the -SSTS prior to final approval by the Department. Projects within..the watershed may also require DEP review and approval of other aspects of a project, such as stormwater.plans._or. the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. : -- -- - f If the application is signed by a person other than the applicant shown in Item l .,the applicat' rf nust .- - -be accom anied b a Letter of Authorization Form LA -97 . Failure to comply l with thi& o vision. P Y ) PY may be grounds. for the rejection of any submission. � I hereby affirm, underpenalty of perjury, that information provided on Phis form is'irue to the best of my knowledge and belief. False statements made herein are punishabMe vs -- a Class A misdemeanor pursuant to Section 210.45 of the Pend Law. SI G:NA T URES& OFFICIAL TITLES: , Mailing Address: ..... :..:::�Q w W. GIV L_�° Jf� i6 05 AUK _._ 01 pi PUTNAKCQUNTV. :DEPARTMENT IOFHEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE. TREATMENT SYSTEM 0, Address AW-Hjtk,-F,9- -1CdAoJWvV P V15 B.!-'ck* Located at (Street) Tax Map o. (indicate nearest cross street) Municipality Watershed SOIL, PERCOLATION TEST DATA Date of Pre-soaking ON Date of-Percolation Test .� J r� `�� 5�2�1g4�� -- — -- ----- 1A) I 2 3 jM 4 5 2.- 3 Alu 11146 4 5 2 . i� fir II ° III 2 {�z �Sl _..... H 01-1 i 'M NOTES:.- I ;Tests to bb , ttge'ated'at same depth until approximately equal percolation rates are obtained at each percolation test hole. (ix-; & I min for 1-30 inin/inch, :5 2 min for 31-60 min/inch) All. data to be. submitted for review. ,1.je'pthmeasurements to be made. from -top.of hole. Form DD-97 DEPTH G.L. 0.5' 1.01 1.5' 2.0' 2.5' 3.0' 3.5' 4.01 4.5' 5.0' 5.51 6.0' 6.5' 7.0' 7.5. 1 8.0' 8.51 9.01- 9.5' 10.01 TEST. PIT DATA DESCRIPTION OF SOILS ENCOUNTERED.IN TEST HOLES'. ROLE NO. HOLE NO. HOLE NO. Lo ftti\ Indicate level at which_ groundwatdf*'is encountered Indicate level at which, mottling is observed Indicate level to which water. level rises after being.e.nc.ountered J D ate. Deep hole o6servatio ns made by: N- L Le - ee Design Professional Name:- Vy t4 tb tWA i Fr, Address: S'O oq IV\ Signature: Design Professional's Seal �67 F. ,U W S No. 56124 4�t OA AO EwW C-0 Indicate level at which_ groundwatdf*'is encountered Indicate level at which, mottling is observed Indicate level to which water. level rises after being.e.nc.ountered J D ate. Deep hole o6servatio ns made by: N- L Le - ee Design Professional Name:- Vy t4 tb tWA i Fr, Address: S'O oq IV\ Signature: Design Professional's Seal �67 F. ,U W S No. 56124 4�t OA AO EwW SENDING CO TON DATE : JAN -16 -2004 FRI 10:15 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 919146412404 PAGES : 3/3 START TIME : JAN -16 10:14 ELAPSED TIME : 00'50" MODE : ECM RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... Pagel 3 (including cover sheet) From: Robert Morr% P.E. BRUCE R. F013y IARMA MUNAM RN, M.S.N. P.M. HralA D6welm ' AwwL.V P.Wk /faaee n&r For your infornation D4cm. of Paters Ss"fnt _ For your review DEPARTMENT OF HEALTH �— As discussed I Gwen Road . No! t fir Mf= RSewltw, Now Yoii 10509 a•Ma•r•hrl HsW (Itf)27t.6170 PbcQ45)376.7031 76adms 9.Vkn (44S)27a•6531 WIC (145)271.6671 Pa (845)"1.603s Lry iM•rw�tls• (IlnZ11.60N P¢ W45)371 :6611 . 64edw1(14s)221.5s13 rap45)2294113 FAX COMEU Date: (o t) �l A/N2 E Ll .t _... Ax 0: AA `% - 2 d •.. _. , . To: C�1AQ�) Pagel 3 (including cover sheet) From: Robert Morr% P.E. Senior Public Health Engineer Emergency Response Coordinator For your infornation iaapoad _ For your review _ _ Attached as requested �— As discussed Please call No! t fir Mf= VW00 Vj: kT 4,(1' i in the event of tranamission /reception dimculdes, pleaat contact this office at (945) 278 -6130 ert. 2166. To: Public Health Director In the matt er of application for: 0 VII- �Oso'R —p�p.r �Qi �6 represent that I am an officer or employee of the corporation and am authorized to act -for: Name of Corporation: W i NO ikRn 40K\V -� - Having offices at:.�'�� G1 IO�j'�i Whose Officers Are: President - Name: Address: Treasurer - Name:.. Address: and that I am and will be individually responsible for any and all acts of the corporation :with respect to the approval requested and all subsequent acts relating thereto. - t Signed: lofty gum*. wwr ► Title: V, G"8 l G" !✓ _ -. _ S�� rn to before me this day of • (month) (year)". No Public Corporate Seal Form CA -97 '� ,; �. • . .. : �. ._. .. .. _:: .. __ :;s �;y.' iii K.X MO, r, PUTNAM COUNTY DEPARTMENT OF HEALTH:*, DIVISION OF ENVIRONMENTAL HEALTH - _ -- - LETTER OF AUTHORIZATION RE: Property of �N ®�! �-�rp!'I11*� -- ........ Located at 1000 T/V PMT45�-word. Tax Map #, °° Block A _Lot l0 Subdivision of DE��\1400p Subdivision Lot # Filed Map #�' Gentlemen: Date Filed.. This letter is to authorize RAW Vje N � V Jri- Qr,— a duly licensed Professional Engineer "4 or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above - noted - property in accordance with the standards, rules or regulations. as promulgated by the Public Health Director of:the ^Putnam County Health Department, and to sign all necessary papers on my behalf in connectioa ;with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in - -conformity wirth,the provisions: of Article 145 - -and/or: 147 -of the Education-f;aw •the - Public Health- Law, and the Putnam Cournt�Sanitary Code. - - oF NEwr 9 N(CHp�� -Countersigined: P.E., R.A., # _ Mailing Address Very trulL igned: ZK State l Zip. Q�o� Telephone: Mailing Address:..... State Zi Telephone: Ns) PU Y NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HE® LTH SERVICES 7. APPLIcCA;TION TO CONSTRUCT A.WA-TEP,•WELL please print or type PCHD Permit # Well Location: Street Address: TownNillage Tax Grid # % APPS 141L a VATT- -60d Map %, Block 4 Lot(s) ob Well Owner: N e: N4O- 1- . Ad e s: �( 1E1+� ��C►t -�� n.L Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought __�q+ gpm # People Served 4 Est. of Daily Usage 900 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling Y- New Supply (new dwelling) Deepen Existing Well Retailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding. ........... ............................... Yes - No Is well located in a realty subdivision? ...................................... ............................... Yes i( No Name of subdivision 1) I✓E1ZW P Ap Lot No. Water Well Contractor: T 8J) Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: Town/Village ----- Distance to property from nearest water main: ,---- Proposed well location & sources of contamination to be provided on separate sheet/plan. Date:. Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVER FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. revision or alteration of the approved.plan requires a new permit. Well to be constructed by a water w 11 iller ce ied by Putnam County. Date of Issue Permit Issuin .- Date of Expirati n Title: Permit is Ikon- Transfer abl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT O� Well Location Street Address: TownNillage: Tax Grid #. _ —: Map4Ai Block 4. Lot(s) 4 Well.Owner: Nam d- Address: Use of Well:_ 1- primary 2- secondary Residential Public upply Air cond /hea pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _ Compressed air percussion Other (specify) Well Type Screened Open end casing x' Open hole in bedrock _ Other Casing Details Total length ft. Length below grade ft. Diameter _in. Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded X" Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: Yes No Liner Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet Well Formation Diameter(in) Description Well Log If more detailed information descriptions or sieve- analyges are available, please attach. Depth From Surface Water Bearing ft. ft. Lana surface go, Ail If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information lei Pump Type Capacity & Depth Model I0 EJo ;!1 l Voltage B? l� Tank Type V` 'h/ Volume B 91 Date Well Completed k0�1 Putnam County Certification No. ODD Date of Re ort 1 >5 V Well Driller (signature) I - NOTE: Exact location of well with distances to at least two ermanent landmarKs to be provi on a separate sneevpian. /,ltd xv Well Driller's Name Address: Signature: Date: �I White co HD File; ; or W copy: Yellow copy - Building Inspector; Pink copy - Owner; range copy - ell driller Form WC -97 a PUTNAM COUNTY DEPARTMENT OF HEALTH �> DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT [Well:Location. Street Address: -, of l � G Town/Village: jy' a,/ Tax Grid # Map � Block Lot(s) Well Owner: Name: Address: Use of Well: 1- primary 2- secondary X Residential Public upply Air cond/ seat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing : L Open hole in bedrock Other Casing Details Total length ` l ft. Length below grade _ft. Diameter L4 in. Llb/ft. Weight per fo It Materials: 'Steel _Plastic _Other Joints: _ Welded .X' Threaded _ Other Seal: ( Cement grout _ Bentonite Other Drive shoe: Yes _ No Liner: Yes )6, No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped .. Compressed Air Hours f�_ Yield �– gpm Depth Data Measure from land surface- static (specify ft) i During yield test(ft) _ Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses - are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface �(i " t r> cc C tw i l FYI . If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Infortajion S 5/ /r Pump Typ Capacity Depth ? Model l'% /� Voltage ��� HP Tank Type j;W Volume I� / �;� --� ' , – /! Date Well omple d Putnam County Certification No. Date of port Well Driller (signs ire) N TE: txact location of well with distances to at least two permanent 1 dm ks to be provi on a separa a sheet/plan. 0. Well Driller's Name Address: Signature: % / Date: White copy: H File; Yellow copy - Building Inspector; Pink copy - Owner; Orange co PY - Well driller Form WC -97 i 'RATED ' S., ORS OR /9U.'S'RS TENCH ? OK METAL ♦, a FAE`Rff �� :H 57AIC8 ♦ G EON j f , t ` \f f 1 90 � e 1 f � t • `y • J � I N / , ell , 1 , 1 + `\ / \ O \ 1 \ + 1 \ ♦ \ \ Ste\ �v / 0 O A h � W O �a V� yti 1 i 16. t— NV��G<IN) INV, (62.52 Couc)i J I r !' • I m D / / Jl - -- ly / �y ocn �y� n• y � � sP o� rr r I j , r r sk r J J I � J J r r � r � r , r / x r - r' p9Q e