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Home My WebLink About2613DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -3 -2 BOX 22 02613 ro. ■: �16 �. I T -'Y - . L P ', -. '. ♦ �'FL r 02613 Rev. 3/86 at PUTNAM COUNTY DEPARTMENTOF•HEALTH Division of Environmental Health Services; Carmel, N.Y. 10512 �r / Engineer Most Provide V V -- 7 ID P.C.H.D. Permit N -- — COMPLIANCE FOR SEWAGE DISPOSAL Town or Village Tax Map Block Lot ' J_— 6,4er/applicant Name � �� EN1 /+ Formerly Subdivision Name Subdv. Lot # Mailing Address W T [ p e 1 �` Zip D� )) j Date Permit Issued 712 1 Separate Sewerage System built by e " -ft, Address B i Consisting f g D 0 Ts Gallon Septic uk and i� f /' 6 � 2y jlAk Gil Water Supply: Public Supply From Add or:— Private Supply Drilled by Address — Building Type 1`'0cCA Has Erosion Control Been Completed? Number of Bedrooms Has Garbage Grinder Been Installed? Other Requirements I certify that the system(s) as listed serving the above premises were of which are attached), and in accordance with the standards, rules and Putnam County D par Qent Of Health. Date sv� Certified by. st ted esa tially as shown on the plans of the completed work ( copies qu ations, i actor any w the filed plan, and the permit�ed by the P.E. R.A. Address ] 7- Y_ A,t u 'A- Je `yo- olfl c IJ-3 - yr 054 License No. 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 sew rage system shall become null and void as soon as a pubs': sanitary lower becomes available antl he approval of the private water supply shall become n I and old wha public water supply becomes available. Such approvals are subject to )fl tl change when, in the judgment of the MOW nor qof h, such revolt n, modification or change Is ees V •� Date By Title �� - 3/86 PUTNAM COUNTY DEPARTMENT OF HEALTH ) eer to Provide Permit R Division of Environmental Health Services. Carmel, N.Y. 10512 on CERTIFICATE OF COMPLIANCE �IfION PERMIT FOR SEWAGE DISPOSAL SYSTEM T. 11 t dNAjo town Or vum Located at - az ' Subdivision Name �°� Subd. Lot # Owner /Applicant Name A � � Date of Previ Approval Mailing Address &'1z 571 Town V Zip Tax Map -1J Block-- 4-- -LOt p� Renewal_ ❑ Revlsion ❑ Building Type S,�''fAU" Lot A� 12.3 1+- AIM Only Depth Volume Design Flow G /P /D + �i P NodBcstion is R aired When FIII le completed Number of Bedrooms � L h Separate Sewerage System to consist of-J%&—Gallon Septic Tank an To be constructed by 1 Address Water Supply: Public Supply From Amass or: Private Supply Drilled by 'hAddress Other Requirements represent that 1 am wholly and completely responsible for the design and location of the proposed system(s), 1) that the separate sewage disposal sys em above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules an regu a ions of e u ra FIR County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to 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 builder, that said builder will place in good operating condition any part of said sewage disposal syst Ing the period of two (2) years immediately following thedate of the issu- ante of the approval of the Certificate of Construction Compliance of the orig nal system r any 4repair reto; 2) that the drilled well described above will be located as shown on the approved plan and that said well will be Inst ll, i cc -dance with s, rules and regu a ors of t✓he /_Putnam County Departm t Health. P.E. ►t �+ Date Signed I 1cense No Address .r ¢�s APPROVED FOR CONSTRUCTION: This approval expires aaear from the date issued unless construction he building has been undertaken and is revocable for cause or may be amended or modified when consy'EQ1eQ necessary by the Commissioner of Health. Any change or alteration of construction _ ,..........N:.! aat . se -aae. alilfior primate water supply only. 3 PU1'NAM COUN'T'Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Nevi k3 Mir,P)(- Owner or Purchaser of Building .. it Building Constructed by W 6' " R0 i�_D �:C1p �:Y Location - Street �k.:5�yJ'��A QAiC'i Municipality eft ,dfrqE iStp�Nc� Building Type Section Block Lot Subdivision Name Subdivision Lot # GUARAFPIT;E OF SUBSURFACE SEMAGE 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 "Certificate of Construction Compliance". for -.the. sewage disposal system, or any _._._. ... -..= rep ` irs made me 'E&�such s sti=�m, except where the failure"" to operate.- . properly is pa .by .- ...... __ y A P P° � P Y 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,wthe 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 ZO day of tAmd, 19 8'9 Pi h,�4 L'w ( er) - Signature zee Ro Ad Corporation Name (if Corp.) rev. 9/85 mk Signature Title Corporation Name (if Corp.) Address ioj 17 :P A.:� ��s� %t. .,.a r �. r.wen• nmTnwT nannnm �� +} CIA .e 4C , o„ WALL VVr1r LA11V" 1\liL V1 \1 DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL-LOCATION STREET ADDRESS: TAX GRID NUMBER: W ; WELL OWNER NAME: �f�i ADDRESS: A jz IQ PRIVATE O PUBLIC F' -;U.SE OF- .VJELL 1 = primary . 2 - secondary RESIDENTIAL ❑ PUBLI SUPPLY O AIR /COND.IHEAT PUMP O ABANDONED BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify) O INDUSTRIAL O INSTITUTIONAL O STAND -BY ❑ MOUNT OF USE YIELD SOUGHT 5 gpm: 1N0. PEOPLE SERVED / EST. OF DAILY USAGE KoOgal. REASON FOR DRILLING 9-NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION O REPLACE. EXISTING SUPPLY O DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH g JT ft. STATIC WATER LEVEL _ / L ft. DATE MEASURED DRILLING EQUIPMENT O ROTARY . COMPRESSED AIR PERCUSSION O DUG O WELL POINT O CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE- O SCREENED O OPEN END CASING, VOPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH 4/' ft. MATERIALS: STEEL ❑ PLASTIC O OTHER LENGTH.BELOW JOINTS: O WELDED CdTHREADED ❑ OTHER DIAMETER in. SEAL: O CEMENT GROUT BEN70NITE OOTHER WEIGHT PER FOOT f Ib. /ft. I DRIVE SHOE: YES =NOLJNER:OYES NO SCREEN -:.... DETAILS _ . :. - DIAMETER (in) 'SLOT SIZE LENGTH (It) DEPTH TO SCREEN (ft) DEVELOPED? FIRST O YES ONO ` HOURS'— SECOND GRAVEL PACK ° YES O NO GRAVEL SIZE: DIAMETER OF PACK In. TOP DEPTH ft. BOTTOM DEPTH II. WELL YIELD .TEST It detailed pumping M HOD: O PUMPED tests were done is in- 0 COMPRESSED AIR formation attached? O BAILED O OTHER :0 YES O NO WELL LOG " more 'eta"ed tormatfon descriptions or sieve analyses are available „please. attach. DEPTH FROM SURFACE water Bear. In9 Well Dia- meter FORMATION DESCRIPTION cane It It. WELL DEPTH It. DURATION hr. min. DRAWOOWN It, YIELD gym. Surface �l f- C? WATER irCLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? 0 YES O NO STORAGE TANK: TYPE bVi- t'_ - yT* (z c'` :2v CAPACITY {�Li C�'ti.l... GAL. WELL DRILLER NAME DATE. %LBERT M. HYATT St SONS, INC. � / ' ADDRESS Well Drilling SIGhXTURE • ,,,, ,pATTERSONKNEW YORK 12563 172 rCt 4-r PUMP INFORMATION TYPE,TUX ". rS i 1 IV. CAPACITY MAKER �-6J 1 aS U DEPTH MODEL C VOLTAGE f)HP rFA .... ... _ .. _...... !``ter Yorktown Medical Laboratory, Inc. LAB _._.. - �-- 321 Kear Street e 'Yor- ktown. Heigh' s; . C (914) 21S•3203 Date Taken. 3+t r jg, Di rector :AlGertH.PadovaniU.T.(ASCP) Date Received:' 'N &A /0-0-/7 Date Reported: 3 rq sa Y�OE �1 Collected By: oz Referred•Bys: Sample . Source: LAtORATORY REPORT ON THE:QUALITY OF WATER_ INORGANIC NONMETALS (In mg /L) MICROBIOLOGICAL (per 100 ml) .:_ Ac.idityi To pH = GENERAL.BACTERIA _ Alkalinity:'To pH __ Chloride _Standard Plate Count per ml t 5 Detergents., Anionic (Agar.plate'e35 °C) _ Hardness, Total Nitrogen, Ammonia MEMBRANE FILTRATION TECHNIQUE_ _ Nitrogen, Nitrate Phosphate,. Total- L'/Total .Coliform _ Sulfate Sulfide _ Fecal Coliform _ Sulfite Fecal Streptococcus METAL'S (In mE /L.) MOST PROBABLE NUMBER TECHNIQUE_ Total— Cbli -farm . _. Iron ..._. . _ Lead _ Fecal Coliform Mangainese Mercury Sodium REMARKS (For Laboratory Use Only). Zinc MISCELLANEOUS ANALYSES _ pH (units) Color (units) _ .Odor..(TO N) REMARKS (For Collectors Use) _ _ Turbidity (NTU) c.. less than ./ TNTC = 'Too Numerous To Count:/.COX = Confluent. .THESE RESULTS INDICATE THAT.THE WATER SAMPLE (WAS (XASN'T) (N /A) OF A SATISFACTORY 'SAN ITARY.'QUALITY.ACCORDING TO THTNFV YORK STATE DRINKING WATER.. STANDARDS s ' FOR THE PARAMETERS TESTED, AT THE TIM • NCOLLECTION. -THESE RESULTS INDICATE THAT THE WATER (D* DID) (DIDN!T) (N /A) EET THE SAT- ISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK T DRINKING WATER STANDARDS,' FOR THE PARAMETERS TESTED, AT THE TIME OF,COLLECTION.. N/A = not wt,n1 inw1,1 DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PrHD PRRMTT $ WELL LOCATION Street Address �9J t e o Villa e C y Tax .�,, Grid Number. WELL .OWNER Name. w• Mailing ddress 3e �it� Vii" J, V,& ` vate O Public USE OF WELL 1 - primary 2 - secondary SIDENTIAL ® BUSINESS 0 INDUSTRIAL '10 PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM 0 TEST /OBSERVATION []INSTITUTIONAL O STAND -BY Q ABANDONED ❑ OTHER (specify AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED EST. OF DAILY USAGE gal REASON FOR DRILLING. 01TEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O REPLACE EXISTING SUPPLY ® DEEPEN EXISTING WELL ® TEST /OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE DRIVEN ®DUG ®GRAVEL ®OTHER IS WELL SITE SUBJECT TO FLOODING? YES --�N0 IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. W ®TER WELL CONTRACTOR: Name e Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: �yc YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON REAR OF THIS APPLICATION ON -0 - z ki (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 thirty (30) days of the completion of water well construction, the applicant shall: Date Date 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 rov ed by the Putnam County Health.Department. of Issue: 19 6-1 11kV110 of Expiration: 19_ ermit Issuing Official Permit is Non - Transferrable 2/87 White copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner PUTNAM.(;OUNTY DEPARTMENT-OF HEALTH, DIVISION OF. ENVIRONMENTAL HEALTH SERVICES •, c.. .a.- �-.y:y.;...w_a��..v.- a:._.: c�...a e,w .:<,F.a�:r..... M:.. �. ,.. s.::. ��.,.. �...•...._:... ...:.__.- _:- •- ��.....�.c_,..•'s ._. +-.e. r..a. ov. ..�. _.a ... ._ . rr'...... ..:..�..s....- .._._.�...- ..._.r .... a i- R.= >.::s_. -. r.a Date Re: Property of tp W K Located at (T) UA Section Block ► Lot Subdivision of Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize a duly licensed professional engineeror registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted pr.operty'i:n accordance.with the standards, rules or r- egulations 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 :...�_, syatem--,oiL - s em -s -iii- �eonf.o-rmity_wi -th-- -thy- 147, Education Law, the Public Health Law, and.the Putnam County Sani- tary Code. Very truly yours, Signed Countersigned: Owner of peyty P.E. , R&*. , # 1�t -3 Xlol Address Address %l9�}c�►vil� � �:�� loll 26S`�Fci�t Telephone Town -% .5 .2 / ,5 j..-)- Telephone NAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIROMaIML HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET - CONSTRUCTION PERMIT - �� - .. (Name of Owner (Stye t Location) p CHI`S YES NO DOCUMENTS ® 42 ® _ Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results Perc Hole Depth IF trench provided required e 60 ft. max. Parellel to contours e� a e Q s/s SUBDIVISION Perc (3) Fill cd House Plans - Two sets Well Cvv permit; PWS letter vari e Re nest GENERAL Legal Subdivision Subdivision Approval Checked Zip-approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRED DETAIIS ON PLANS " Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flab Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank Size, Detail Well Detail, Service Line if over Construction Notes Design Data: perc and deep results Two -Foot Contours Existing & Proposed Driveway- &:_Slopes Footing /Gutter, Curtain Drains (discharge OK`) Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shown;gravity flow,suff. size If Ptmped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed System: Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft. 4 "0; Type pipe No Bends; Max. Bends 45° w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees,Top of fi 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (Inc. expa 15' to Drains-Curtain, Leader, Footing 35'to catch basin,storn-drain,piped watercom 10' to Water Line (pits -20') 50' intermittent drainage course Septic Tanks 10' from Foundation; 50' to well 15' Well to PL It A PUI'NPM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS zFIEI� .INSPECTION - TC I "'k p REPORT _.._nip:° INSP. BY: (Name of Owner) (Street Location) INITIAL SITE INSPECTION YES I NO CCMME'S Wetlands on /or proximate to property.............. vp Property lines or.corners found ................... 1 e Canestimate house location ....................... Will driveway need cut ............................ Must trees be•ranoved - note these ................ be Deep holes representative of entire SDS area...... ,Additional deep holes reed ...................... Sufficient SDS area available considering driveway ? cut, house location, separation distances,etc... PAjacentwells /septics ............................ pc Access to ur000sed well location for drillina..... I P. H. 1 Lot Depth to G.W. Depth to rockri- (� cawe0t �^ Soil Description Some. o ft. E 3 ft. I SPO� LOAM t* 6 ft. 9 eft. i2--ft D. H. 2 Lot Depth to G. W. Depth to rock T Soil Descriotion��vv�t- 0 ft. r— M'PSOi 3 ft. I SAA� LOAM 6 ft. 9 ft. 12 D.H. - Deep Hole G.W. - Groundwater D. H. 3 _ Lot - Depth to G.W. Depth to rcc-k Soil DescriDticn 0 ft., F I 3 ft. 6 ft. 9 ft. 12 -ft. DATE: FINAL SITE INSPECTION INSP . BY : YES NO CCMV -ENTS House SSDS located per approved plan ............. Length of trench measured Width of trench average Slope of tile line and trench acceptable.......... Room allowed for expansion trenches .............. Over 100 ft. frcxn waterccurse .................... Natural soil not stripped or SDS area unnecessarlygraded ............................ 10 ft. maintained fran property line and 20 ft. fran house .............................. Distance well to SSDS (ft.) ...................... Nmberof bedrooms checks ........................ Stones, brush, stumps, rubble, etc., greater than 15 ft. fran nearest trench ................ 15 ft. of peripheral soil horizontally frantrench ..... ............................... Boxesproperly set ............................... Could surface runoff fran driveway, roads, ground surface, etc., channel near SDS area.... ( + Does lot drainage appear OK,iri area of SDS::...... j FINAL GRPDNG OF SITE P_C'CE2'�'AME... ... - A .- R4 co 0 WELL LOCATION WELL COMPLETION Khrum, office Use Only DEPARTMENT OF HEALTH PUTNAM COUNTY DEPARTMENT OF HEALTH _ STREET ADDRESS: MWN1ViLLAC1jCiIy TAi GRID NUMBER: itc rJ11& IiA �4L W.ELL.OWNER NAME: AOOAESS: Ili cnl'o PRIVATE 0 PUBLIC .. =E OF- .WELL primary 2 - secondary RESIDENTIAL 17_1 DHnf 1"UPPLY ❑ AIR/COND./HEAT PUMP ❑ ABANDONED � BUSINESS 0 FARM ❑ TEST/OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY ❑ MOUNT OF USE YIELD ISOUGHT gpm./RO. PEOPLE SERVED EST. OF DAILY USAGE K0()gaI. REASON FOR DRILLING •NEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY ❑ TEST/OGS-RVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL . DEPTH DATA W L DEPTH 895- EL ft. 11 STATIC WATER LEVEL - 70 ft. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY VCOMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE- ❑ SCREENED ❑ OPEN END CASING, VOPEN HOLE IN BEDROCK 0 OTHER CASING TOTAL LENGTH fL MATERIALS: .12(STEEL 0 PLASTIC 0 OTHER LENGTH.BELOW GRADE ft. JOINTS: ❑ WELDED OdTHREADED ❑ OTHER DETAILS DIAMETER in. SEAL: ❑ CEMENT GROUT BENTONITE 0 OTHER WEIGHT PER FOOT 2 1b./ft. DRIVE SHOE. VYES ONO I LINER:OYES NO SCREEN DIAMETER (in) SLOT SIZE LENGTH (11) DEPTH TO SCREEN (ft) DEVELOPED? FIRST .Q-YES 0 NO HOURS SECOND GRAVEL PACK - 0 YES 13 NO GRAVEL SIZE: DIAMETER OF PACK In. Top DEPTH ft. BOTTOM DEPTH It. WELL YIELD .TEST It detailed pumping MgHOO; 0 PUMPED tests were done as is.- El COMPRESSED AIR ol formation attached ? 0 SAILED 0 OTHER 0 YES 0 NO 'er, rmation descriptions or sieve analyses WELL LOG 11, more dehi are available, please attach. DEPTH FROM SURFACE water Sear. ing Well 041- octet FORMATION DESCRIPTION coat it. WELL DEPTH It. DURATION hr. min. D9AWOOWN1 It. YIELD gpm. S.r Lanld ce a e� WATER iCLEAR TEMP. QUALITY 0 CLOUDY HARDNESS 0 COLORED ANALYZED? 0 YES ON ANALYSIS ATTACHED? 0 YES 0 No STORAGE TANK TYPE LVj: ='t yj- (I CAPACITY GAL. PUMP INFORMATION TYPE] X&V. rl i 6 /V- CAPACITY MAKER &6jkfX5 DEPTH W MODEL r I Q VOLTAGEa36Hp WELL DRILLER NAME DATE kLBERT M. HYATT & SONS, INC. ADDRESS Well Drilling SIGftATURE Rte* j1 I .R. 2 Box 171A PATTERSON, KNEW YORK 12563 "W — / i It' r , / SHERLITA AMLER, MD, MS, FAAP Commissioner of Health y LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH I Geneva Road, Brewster, New York 10509 Wayne Geriak 142 Wiccopee Rd Putnam Valley, NY 10579 June 24, 2008 Dear Mr. Geriak: ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health Re: Proposed Well Geriak 142 Wiccopee Rd (T) Putnam Valley A field inspection was conducted on the above referenced lot by Mitchell Lee, Public Health Technician. The application to drill a new well is approved with the following stipulation: 1. A Well Completion Report (WC -97) shall be submitted no later than 30 days after the well completion by the permittee. Please contact me at (845) 225 -5186 ext.2233 if you have any questions. �A S' Ychell MD. Lee Public Health Technician Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 0, a (i6lp� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES , r � _ ....•APPLICATION TO CONSTRUCT A4 WATER �WELL , , �... ,..a..Y,,.., ... ,..�: ,,...< � _..., _......,... please print or typeCliff iPefmlt � _ mM Well Location Street Address: Town/Village: Tax Map # �L. VVtZ.Z� t)k 1 V N I /O) ?lap Blocki Lot(s) Well Owner: Na_me: Address: f A ,; u0 Phi ell: Residential _Public Supply Air /cond /hea pump _Irrigation 1- Primary Business Farm Testimonitoring — Other(specify) 2- Secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily usage gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason By wo, 1i I h 6 S*V�Z, Ituej, for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding?... . ....... .............. * ....... ........ Yes No Is well located in a realty subdivion?................... ........... Yes No Name of subdivision Lot No. �. Water Well Contractor: Address: Is Public Water Supply available on 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 sh plan. _t !_ 19laSure _:- L t 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. :; . �n ; .. -;� r d`3.:.:z.� ..r., s n� .4a, c �x � -: 4 rT,he;well driller shallablde by apcondltloris of thertpermlta 5) :During all,well drlllmg, o eratlonsthe welIt," dnllershall x , .� , ._...,... �,.. . q- . < . _ . ..._� �.LO p._..., a.0' .N. ... _......... 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. APPROVED 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 Commissioner of Health. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. A Date of Issue Permit Iss ing O Icial: l/z Date of Expiration Title: Permit is Non- Transfera White copy - HD file; Yellow copy - Building Inspector; Pink copy - OneA;.Orange copy- Well driller Form WP -97 Rev. 3/06 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH .SERVICES APPLICATION TO ABANDON A WATER WELL Description of Work To Be Performewd- 1 P P 4 JA)d I - 46 Lek� - I k l : l0 v Applicant Signature: � PP g 10196111 6?- (,AAC> Lk4 This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and /or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. I A _ f � Date of Issue Permit Issuing Of cial Tit White copy: HD file; Yellow copy - Building Inspector; Pink -copy - Owner; Orange copy - Well dri Form WA -97 please print or type PCHD PERMIT # .3 -0 Well Location: Street Address: H � TownNillage lx P V rA 01 J001 � ir Grid d� l Map Block Lot ( ) Well Owner: N me: lAddreas: uj� Ve Well Type: Drilled Driven Dug Gravel Other Depth Data: Well Depth OW ft Tstatic Water Level ft Date Measured Use 1: Residential Public Supply Air /Cond/Heat Pump Abandoned 1-primary :2-secon primary Business Farm Test/Observation Other (specify) ary Industrial Institutional Standby Water Well Contractor: Name: �� Address: �k jai� � Sa/�S Cr l Reason For Xi 7 u4 t kS A o Mcorky Abandonment: Description of Work To Be Performewd- 1 P P 4 JA)d I - 46 Lek� - I k l : l0 v Applicant Signature: � PP g 10196111 6?- (,AAC> Lk4 This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and /or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. I A _ f � Date of Issue Permit Issuing Of cial Tit White copy: HD file; Yellow copy - Building Inspector; Pink -copy - Owner; Orange copy - Well dri Form WA -97 • a �r, , i hm dyer 5 1 r• •• 1 a• • •�r la • : y r: 1 r • - a r,r is v •��• �: tia• tea. DESIGN .DATA SHE T- SUBSUFACE SEWAGE DISPOSAL SYSTEM Owner Address Pn M. Located at (Street) u' • <<o e p e� Sec. IT Block 1 ]Got 1 � (indicate nearest cross street) Municipality ?, \)"w'� 0-y- Watershed Date of Pre- Soaking - S! i It, Date of Percolation Test kL9•R`i HOLE N(KMR CLOCK TIME PERMEATION PERCOL 1TION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start Stop Drop In Min,/In Drop Inches Inches Indies l 77 z't 21 3 9 A 2 30 'Z`E i� 21 3 t o t . 3 .3e z.1 3 o t 4 30 5 2.1 70 25 27 %y toA 2. 3 Ic 25 2714 - I2 Z 4 27 r�2 2 12 Z 5. 1 2 3 NOTES ��. Z1eAs i 1. for xe� 2:`— Depthri rev. 9/85 _...._... ro►.fie� repeated at same- depth until approocimately equal soil rates d .at 'e+ach' Vco644on test. - bole.. All data• to`.be suimittad ;9asurements to be made from trop of hole. DEPTH HOLE NO. 1 G.L. 11 21 41 V-4 51 71 81 �1 • 1'• 1 Y:!J V: • � a �v1 11a!• �� r 1+a.Z+y HOLE NO. Z EM NO. 91 101 M1 -eJ e-i • 121 �.. ,. 131 141 INDICATE LEVEL AT WHICH GROUNIXnWER IS' EN00UNi'ERED' _- INDICATE LEVEL TO MICR MTER LEVEL RISES AFTER BEING EN00(VMM _ m DEEP HOLE OBSERVATIONS MADE BY: 1;� At" U DAZE: 5 91 DESIGN 2 «- -k.5 °' S.D.. Usable Area Provided- _ 5" ..: _. Soil Rate Used • � Mi.n�%1. -- Drop. -- -- ..._.. - .�- - -No. of Bedrooms 3 . - -Septic•Tanil Opacity..... . gals,. Type c • Absorption Area. Provided. BY- . -__ `3Y._. _._:.L.F... -x. 24". width trench....., Other.... Name `rc «�� r . �, -' `'` . S. gnature Ne Address SEAL A . .. .. :y.t.:a.w.— .:gu ...i..aard nw."•+✓i'�,,;.UL;iC _.. }_ ,:.i.�•.,•...i 1'(f .:•.�•:•jY' Z .��rtt .. 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