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HomeMy WebLinkAbout2202DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 39. -1 -2 BOX 19 'Irm I% „ NJ IN , B , I 1.6 , 1 NJ IN, i 02202 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTERS CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WILL LOCATION --Street Add ess 3vAf fAo Town/Village/City Tax Grid Number l ��4JA Ih V Attic-1 WELL OWNER Name � �I to Mail' g Address BLS tGic- �� b RIIV6- aPrivate 0 Public . USE OF WELL 1 - primary 2 - secondary elESIDENTIAL ® BUSINESS © INDUSTRIAL . 0 PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP 0 FARM 0 TEST /OBSERVATION 13 INSTITUTIONAL 0 STAND -BY 0 ABANDONED 0 OTHER (specify) AMOUNT OF USE YIELD SOUGHT t, t S gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE x,00 gal 13 PLACE EXISTING SUPPLY 0 TEST/ OBSERVATION 13. ADDITIONAL SUPPLY MNEW SUPPLY NEW DWELLING 03 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR 'DRILLING TELL TYPE MDRILLED D DRIVEN ®DUG ® GRAVED ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES ENO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. - HATER WELL CONTRACTOR: Name Address:— P � IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES / NO HAKE OF PUBLIC WATER SUPPLY: N'A' TOWN /VIL /CITY 'DISTANCE TO PROPERTY FROM REAREST-WATER'MAIN: - _ P1 LOCATION SKETCH ,PSOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET Sigt (date) (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 thirt }� (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 drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. c�- Date of Issue: Date of Expiration 19� Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well .Driller PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES " .. ._ • ..,ter .. oi... < .. s - - • .... „fin .... _ " .. ....- . � -.. .. .. _ .... .... . .. - ... - .. { Date jq q' Re: Property of Located at (T) o i Section 6.� Block 6fp Lot ri I Subdivision of Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize, a duly licensed professional engineer or' registered. architect (Indicate to apply for a! Construction. Permit for a separate sewage system,. -t'o..', serve -the above noted property in accordance -with the standards, rules k or,;regulations as. promulagated by' the. Commissioner. of the Putnam County Department of Health, and-to sign all necessary papers on my behalf•in connection with this matter and to supervise the construction.of.said' system' or systems in conformity with the provisions of Article .A 5 or 147,•Education Law, the „Public.Health Law, and'the.Putnam•Count.y,Sani- tary Code. Very truiy:. rs, �. Signe Countersigned: Owner. Property o 3 •• P.E. , mac. , # y 3� Address •Address• Town _ • N;c:i� A. -.,•M1 � •. iv� - 9 0'16 j l� � l�� 1"��.” off` �'?�.DT: Telephone 2G-s- V 01 g r b p(nMM, CaWY DEPARTMENT OF HEALTH DIVISION CF aNDIMIE= HEALTH SERVICES DESIGN MIA S(3.L•'ET- smsuL•'ACE SLWIGE DISPOSAL SYSTEM FILE NO. Owner �� ©2��ictt Address $25 Located at ( Street) 9t1�u ooiCtZQ.. U1�(cowtiSec. Block d .Lot Z (indicate nearest cross street) l Municipality �.:"'^ : la �U1' Watershed, sLw- SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITI'E7J WITH APPLICATIQNS'`' Date of Pre- Soaking z.a . a Date of Percolation Test _ +� 2,q A/ . HOLE NUMBM CiACR TIME PERCQLA M, 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 "Z.33 2 2� L� r 3_ g;,�: L i 3 J S ._ 1 A 21 y� 2i 3 q.o 5 4 ' 5 _ 0 NOTES T: Tests to be repeated'at same_depth until approximately..;b'ual soil rates are obtained.at each percolation test hole. All data - ".* —be subnittih-i for review. 2. Depth measurements' to be made from' top o`f hole. rev. 9/85 2 22 d 2 3 ._ - -- 4 ' 5 _ 0 NOTES T: Tests to be repeated'at same_depth until approximately..;b'ual soil rates are obtained.at each percolation test hole. All data - ".* —be subnittih-i for review. 2. Depth measurements' to be made from' top o`f hole. rev. 9/85 TEST PIT DATA T-MUI= TO 11C SUBRITrM WI'111 APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEM HOLE NO. l HOLE 1b. Z. HOLD NO. G.L.- 20 31. 40 59 61 71 81 91 10" 121 131 14, INDIPATE LEVEr, ATM= GRMMMTE.R IS ENCOUNTMED.. INDICATE LEVEL. To WHICH vmTER LEVEL RISES AFTER BEING ENCOUNTERED DEEP. HOLE OBSERVATIONS MADE BY: DATE: ---------- 1--v 1— DESIGN Z. Soil Rate Used 11&—, Min/111 Drop: S.D. Usable Area Prov ic led S, + No.a of Bearocms Septic Tank Capacity gals. Type Absorption Area Provided By 0 L.F. x 24" width trench Other Address V7 2 M..." :5e. Signature. K4% SEAL /Osa A10- 4 3 7 r WA-- 4. THIS SPACE F%•E BY HEALTH DEPARTM ONLY: Soil Rate Approved sq.ft/gal. Checked by Date M; SYSTEM PROFILE I " =10' DESIGN DATA: DEEP HOLE TEST: DEPTH TO PERCOLATION TEST: HOLE WATER IMPERVIOUS 8-10 T, slc'_•!Ilzed rote min. /In. I z �'• �'• DESIGN FLOW: 600 3 gals /day 4 APPLICATION RATE: 0�9 qpd /sq. f1. REQUIREMENTS: 1000 gallon septic tank .333' Z' wide abs. trench distribution boxes . Junction boxes cleonouts ' c. y. R•09. fill c.y. Impervious M 910' *Vu— County Department GI ae"T , '1vie100 of Bovir0nme1113al Health 8ervioe. Approved as noted for oonformanoe with 40110able Rules and Regulations of the Putnam County 8 Department.