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HomeMy WebLinkAbout2714DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 61. -2 -27 BOX 23 02714 Coneteting of 100: Gapon Sepdc'Tank and 1gZ �-i•� C�-� G�i. �! Watei Supply: : Public p1. From IAdd *as or: prlyate Supply DriIIed by �Addreee g��g Type t00 1 I %�.L% Hae Eroalon "control Been CompletedY Number of Bediooma Has ;Garbage Grinder Been InetallOR. Other Rogalremente ,,i'` ©' 1 1. ; �.' ►.I�ci� Y:certify that the system(s),as listed eervinq the aboye,premises were constructed essentially; ass a, plans of the completed work ( copies of which are attached), and, in accordance with the standards, ru les. and reguletio s,•i' acc anoe w t$ fil plan, and the permit issued by the Putnam Count Depar Ant O! Health Dats Ce►tifled 0 Addiess License No. v Any person occupying premises served by the above systems) shall promptly take such action asmay be neoesy►y t secure tM correction of any unsanitary condMgns resulting „from Such usage .Approval .of thoi.'separate siweray6'system shall become null and, void as soon as .a pubt(c unitary .s vi er becomes available and the approvpl of the; p�ivafe °water ;u_Dply shall become; cal red 4616 =when i.,publie'wata supply becomes Available. Such approvals are subiect to mOdificatlOn, or('Man�e. when, in the Judgment of the, o s oner of M . such revocation, modification or change I airy. Date I l _` 8y Tit f- 97"o. —: .' r > DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 MEMO TO: MR. WILLIAM CARLING, JR. COMMISSIONER OF E E FROM: MR. JOHN KARELL, JR. PUBLIC HEALTH DIRECTOR' DATE: JAN. 25, 1994 We accepted and deposited a check from Mr. Roger C. Rhodes, in the amount of $300.00. The fee for the compliance was $200.00 so he is due a refund of $100.00. Please send refund check of $100.00 to: Mr. Roger C. Rhodes P. 0. Box 1550 Radio City Station New York, N. Y. 10019 Please send us a copy for our records. Thank you. JK:EP cc: C. Johnson �M X0 WELL COMPLETION REPORT Office Use Only / ►°� DEPARTMENT OF HEALTH .__ .......- ... -..� .. . t - Y:� � - Jlair�,r ^a3.�n -s•�� E}�,�.' q.��c ^ti:�...An_a�'3C-.ii' S.AZ'.7�s_e� . - - - - - - - �w Y0� PUTNAM COUNTY DEPARTMENT OF HEALTH STREET ADDRESS: TAX GRID NUMBS WELL LOCATION s f l00 � /( X04 r r ! st s►, WELL OWNER N E. ADDRESS: %1- �1nc� -es P.o o v C� 411,14e. U PUBLICS USE OF WELL E IOENTIAL ❑PUBLIC SUPPLY O AIR/COND./HEAT PUMP ABANDONED 1- primary ❑ BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify) 2 - secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY ❑ )MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR .[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY DRILLING BREW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH `3xo ft. STATIC WATER LEVEL �� ft. DATE MEASURED a Lv� DRILLING ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED QGPEN END CASING ❑ OPEN HOLE IN BEDROCK ❑ OTHER TOTAL LENGTH ft. MATERIALS: &STEEL O PLASTIC O OTHER CASING LENGTH BELOW GRADE __JA S ft. JOINTS: O WELDED Q THREADED O OTHER DETAILS DIAMETER in. SEAL: CKEMENT GROUT 0 BENTONITE OOTHER WEIGHT PER FOOT Ib. /ft. DRIVE SHOE: O YES 0W10" LINER: G YES MAO SCREEN DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? DETAILS FIRST ❑ YES ❑ NO GRAVEL PACK ❑ YES GRAVEL DIAMETER TOP BOTTOM C3 NO SIZE: OF PACK in. DEPTH ft. DEPTH It. WELL YIELD TEST If detailed pumping WELL LOG '. If more detailed formation descriptions or sieve analyses are available, please attach. METHOD: ❑ PUMPED tests were done is in- DEPTH FROM water well VOMPRESSED AIR , formation attached? SURFACE Bear. O'a- FORMATION DESCRIPTION CODE ❑ BAILED ❑ OTHER ; ❑ YES O NO ft. fL ing In WELL DEPTH DURATION DRAWDOWN YIELD Surface rt It. hr. min. IY, 9pm. f7�� -r 6 r~ r WATER O CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? OYES ❑ NO ANALYSIS ATTACHED? ❑ YES ONO STORAGE TANK: TYPE Lie II -x tell :kdsd PUMP INFORMATION CAPACITY GAL. TYPE S<< < CAPACITY WELL DRILLER NAME DATE MAKER act.,. DEPTH 320 ADDRESS Nd {M6, 00-41sr, SIGtT7t M MODEL VOLTAGE HP - 0 na x 6 s Y . �a �a Vy(fi U 'YML Environmental Services . . . . . . . . . . . . . . . . . . ............... -1059 ELAP #10323 (914) 245-2800 Al Ck,, IC-L) /,�)W COLD BY I & �- -,_ 4 CGS 1 NOTESI (2-/ z- Z- 1f9-- S-� Y,,C- RESULTS OF WATER TESTING X ANALYTE RESULT UNITS? ALKALINITY. DATE/TIME RC-D mg/L /0 AMMONIA DATE REPORTED mg/L 1%2 ARSENIC mg/L CHLORIDE mg/L A) y 10J--2-11 COLOR For Lab Use Only Units Z Potable — HN93 — pH LT 2 <jC CONDUCTIVITY Ll <20>4C urnhos/cm >20C STAT! H2SO4 ZnOAc COPPER NI MPN mg/L DETERGENTS mg/L e -F'L'- -6 61i -16' E- " 7 HARDNESS mg/L IRON mg/L LEAD mg/L MANGANESE mg/L SPC MERCURY mg/L TOTAL COLIFORM NITRATE per 100 ml, mg/L FECAL COLIFORM NITRITE per 100 mL mg/L E. COLI .ODOR per 100 ml, TON FECAL STREP., pH per 100. mL S. LAB NUMBER F— :*.37. 0070 J RESULTS OF WATER TESTING DATE TIME TAKEN ANALYTE RESULT UNITS PHOSPHOROUS DATE/TIME RC-D 12-4�' /0 SILVER DATE REPORTED NOV 2 7 1%2 SODIUM mg/L SAMPLING SITE A) y 10J--2-11 SULFIDE For Lab Use Only mg/L Z Potable — HN93 — pH LT 2 <jC Nonpotable — NaOH _pHGT9 Ll <20>4C HCl Na2SO3 >20C STAT! H2SO4 ZnOAc TURBIDITY NI MPN RESULTS OF WATER TESTING X ANALYTE RESULT UNITS PHOSPHOROUS mg/L SILVER mg/L SODIUM mg/L SULFATE mg/L SULFIDE mg/L SULFITE mg/L TURBIDITY NTU' ZINC mg/L e SPC per 1.0 mL TOTAL COLIFORM per 100 ml, FECAL COLIFORM per 100 mL E. COLI per 100 ml, FECAL STREP., per 100. mL These results indicate that the water sample [WAS] [WAS NOT] [NA] of a satisfactory sanitary quality according to the New York State, Sanitary Code for. the ram er§ tested, at the.. of sample collection. AS]' ram 4 ba Am� These results indicate that Ithew ter ample [WAS] [WAS NOT] NA). ..a satisfactory chemical quality according to the New York State San ar Co e for the parameters tested, at he tim of sample collection. NA = Not Applicable N = Not Present (Negative) SUBMITTED BY. P = Present (Positive) SA = See Attachment(s) i� * Also done because,Total Coliform was present Albert H. Padovani, M.T. (ASCP) TNTC = Too Numerous To Count Director > = GT = Greater Than < = LT = Less Than PUTNAM COUMTY DEPARTMENT OF HEALTH -- �, Owner or Purchaser of Building /fix 6-T, 4ID a�6 Bailing Constructed by -A kt -126 2-5-ZOO K �T Location - StreetVA.i-LB �taA�, � Municipality jIyELk TI A, (., Building Type Section Block Lot 4r' rrm" d Subdivision Name a Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and 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 :. «,_:..... _. ��n +- $.£.:,....�.. .�F.;.�;_ :.�,- .,..� -� . .. Q+t„n� lc''•. ^�An •ice': �- rte ,,ccxaYcrc..���c�i':..���;i`rn+. nr_ .+ 3�....._� ...,.. 've'r`�.i�i�.ci:..v ^'vi. ...vPiv�.i'cx-ti.- C,••2 . ..t.� .. ... >.. ......�- ..,- �.....• ,,..r11 -.... 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 build' utilizing the system. Dated this day of �, A,�j 19 cl Signature Title Do N General Contractor (Owner) Signature --F-VC &z c,� Corporation Name (if Corp.) Address rev. 9/85 mk Corporation Name (if Corp.) IVY- y,tt�V I ess . be 'submitted to the Department; and ,a written :guarantee Will be'furnished th0 owner', h14s000esSOfS� theirs Or ass ig y'•[f18 /pUiltlef, that. saic Duncier will place :in good operating condition any part q. sewage disposal; system :luring the period'of two (2) years in a lately following ihedai of the issu- ance. of, the approval of the &iiificata of Construction Compliance, of ttie ogginal,systom or shy r irf theret , 2 that the drtlted well described above will�be located as shown �n the approved plan and tKit said well will be tnstalie4i' an with t sta rds L s a regu aeons of t Putnam County Depart ant,'-c; ealth Signed - P.E. R.A..- Adtlress /1, icense NO APPROVED FOR CONSTRUCTION: This approval expires ^ r'from the ;date issued unless construetlo - of the building has been undertaken and is revocable for cause,' ause or maybe amended or, modified when considered necessary the Commissioner of Heal h. Any change or alteration of construction requires a new permit:, Approved for-'disposal of domestic'' sanitary 'sewag'e,`'and /or'private. water supply only'. Title Date 9y _ a. PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONKENTAL- HEALTH SERVICES INDIVIDUAL WATER SUPPLY /SUBSURFACE SEWAGE DISPOSAL SYSTEMS DATE: 0� 'UIOIL , "`'U ` INSP. BY: (Name of Owner) (Str6et Location) INITIAL SITE INSPECTION I YES NO COMMENTS Wetlands on/or proximate to property.............. Property lines or corners found ................... Can estimate house location ....................... Will driveway need cut.... ...... o ......... oo ....... Must trees be removed - note these ................ Deep holes representative of entire SDS area...... Additional deep holes needed..... ....... .... Sufficient SDS area available considering driveway cut, house location, separation distances,etc... Adjacent wells/ septics ............................ D.H. 1 Lot Depth to G.W. Depth to rock Soil De. 0 ft. 3 ft. 6 ft. 9 ft. 12•.. ft D.H. 2 Lot _ Depth to G. W. _ Depth to rock Soil Descr 0 ft. 3 ft. 6 ft. 9 ft. I I D.H. - Deep Hole G.W.- Groundwater D.H. 3 Lot Depth to G. W. Depth to rock 0 ft. 3 ft. 6 ft. 9 ft. .. ,x:7.2 ft.. Soil Descri DATE: FINAL SITE INSPECTION INSP.BY: YES NO COMMENTS 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. from watercourse.... ..... o ... o ... oo. Natural soil not stripped or SDS area unnecessarly graded........... ..... ........ 10 ft. maintained from property line and 20 ft. from house... ..... . ........... ... ..... . Distance well to SSDS (ft.)., ... 0000..o.o.o.00.o. Number of bedrooms checks ..... . ..... .:........... Stones, brush, stumps, rubble, etc., greater than 15 ft. from nearest trench.. .. ........... 15 ft, of peripheral soil horizontally from trench..... ......................... Boxes properly set......... .................... Zould surface runoff from driveway, roads, ground surface, etc., channel near SDS area.... Does lot drainage appear OK in area of SDS....... FINAL GRADNG OF SITE ACCEPTABLE.......... .... 4" , . PETER C. ALEXANDERSON County Executive DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914) 225 -0310 April 27, 1987 T. Michael Daly Box 243 Shenorock, New York 10587. RE: Proposed SSDS Rhodes Philipse Brook Road 23-5-1.1-2 Dear Mr. Daly: JOHN SIMMONS, M.D. Deputy Commissioner JOHN KARELL, Jr., P.E. Director Review of plans and other supporting documents submitted at this time relative to the above captioned project has been completed. Comments are offered as follows: For trigalley design it must be demonstrated that 8 foot deep holes are possible in the SSDS area. Current data only show 7 foot deep holes. _.._ e . sheet. i -. provid a_ new designer data eetor..new des gne _ Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. bier tr y yours, - Anne tner Asst. Public Health Engineer AB: pt cc: JK Pile -. r-. — - -r -- / PUTNAM COUNTY DEPARTMENT OF HEALTH } t t r R6-V. 3/86 ..1��3 Division of Envlronmenta! °Health -Services: Carmol. N:Y 10511; L° EnBlneer'to Provide Permit H 13 on CERTUFICATE OF COMPLIANCE Permit b V CONSTRUCTION, PERMIT FOR,SE AGE DISPOSAL SYSTEM 'Located at 1L- OPi.� Town or ;VWago Tax` Sabdlvlslon Name Sabd. Lot li Map tt Block Lot , Renewal_ O Revision LAY v Owner /AppUcerit Name- C7 p f Date of Prevtons Approval'PJ 'j�ri'e1 Vll .�'L•�b1,' (^a�' Town v. z 1OO'19 Moft Address �' BdUding Type �� i7e� �d c- Lot Area � • FIU, Secdon Oply Depth Volume Nembor of Bedrooms Deslp Flow G7P/D PCHD Notl6cadoo,ls Repaired When FS le completed Sepati pte Sewerage Systept to consist. of �.a Mallon So' Tack and To he consthkted by T'o .�, i7. Address Water Sapply < PdbUc Supply From Addeese or: Prlvate SaPP1y ll IDed by -' 17 - Address represen that I am wholly and completely responsible for the des�gnand location of the "proposetl S);.1) that the separate sewage disposal` system above described will'be'cdnstiuCted as Shown on the approved amendment there t0 and_in. accordance with the stantlartls; rules an .regu a ons o the' Putnam County" Depa tment of Health,.,antl that on completion thereof a'•CertifGte of Construction Compliance satisfactory to the commissioner of Health will be ,submitted to the Department and;a `wntten;';guarantee .`will ba Yurmshed' the owner his sticceuois, heirs or assign; by the builder, that said tiulider will place ;in' good operating condition any ;part ofsaid sewage disposal system'.,'tluring ^the per�od:ot two (2). years medlataly following thoda ;'e of the Issu- ance.'of the,aDproval:'of .the Certificate q. of the o►igmal,,syst, or: any repairs th ' t' '2) that the drilled.well described above Will, be located as shown on t"e approvedplan and that said well w�p',b'elnstalled with a sta s,,, les regu a ons of the. Putnam 1. County Depart men oP.H alth r� P.E. �� R.A. Date" { � Signed�< Atltlress Z l lcenw No r APPROVED 'FOR CONSTRUCTION: This apProdal expires one year:fr6m ih6`date issued unless construction of a building has been undertaken, and Is revocable for cause or may.:be amentled:'or modifiedwhen considerednecessary-, by the Commissioner of Health. ny change or alteration, of construction requires as nnew�-perrmiit.� Approveed 'for disposal of domest,Ic sanitary sewage; and /or rwate water ply only, Date 4W C94 +Ut_ Yi t!� b ey' ' �ltle DEPARTMENT OF-HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO- CONSTRUCT.A WATER WELL. . - .rte- - 7 .. .... ..• .. w ..- �. t tic. PCHD PERMIT #Ay.' WELL LOCATION Street Address 1 '— Townf Village C Tax R �ity n Grid Number -s —) ~ la Z WELL OWNER N e Addr ss Cd private O Public USE OF WELL 1 - primary 2 - secondary RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP ® BUSINESS O FARM O TEST /OBSERVATION 13 INDUSTRIAL O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify 17 AMOUNT OF USE YIELD SOUGHT 6 gpm /# PEOPLE SERVED lv /EST. OF DAILY USAGE 490 gal REASON FOR DRILLING EW SUPPLY [3REPLAC5 EXISTINq SUPPLY O PROVIDE ADDITIONAL SUPPLY ODEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING °-, WELL TYPE GVeILLED DRIVEN ODUG 11 GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES ---1G0 IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:_ r Lot No. WATER WELL CONTRACTOR: Name —r,. 16 t- Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES LAO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY ?DISTANCE TO PROPERTY. FROM NEAREST. [4ATER. MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION A S 1 A,P,e,�e t&7b,23 ­ . (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: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. Date of Issue: 19-rib_ ; Date of Expi ration ,e, 19 : Permit is Non - Transferrable 8/86 II. 11.7. V71. l d Y _ ' APPENDIX C i'• I FINAL SITE INSPXTION Date -� j TIO ► V c �L� � `� CW i i • :`l _ .. _ . - �Y`i ff - OR Su�ui v m M-li:ii"Q' % _ •. VV („�� V r_C �T(•I / rv^w,ni.rc•.•rrv- ScZy�S -.c DISPOSAL AREA a_ SDS area located as per apn_roved plans - b. Fill section - Date of:pl nt 2:1 barrier _ - WZD'I'fi A_VG.DPTH _ c. Natural soil not s t= ipped d. Store, brush, etc., qre =_ter tin 15' from SIDS are-_-_ e. 100 ft_ free water course /wetlands. Schur -.� DISPOSAL SYST� a. Septic tank size 1,000 1,250 I b. Septic tank ir_st=? - eve- I c. 10' minirnan from fcundation d_ No 90° bends, cl e-=-^_cLt within 10 ft. of,-4-5' e_ DIS=U --TION BOX 1. A L 1 outlets at same e-etraticn - wa.tsT testes � t'`�'' 2. Protected be-cw frost 3. Mi nimu-n 2 .ft. ericinal soil between box and t--=mows I I f. JUNCTION BOX -- prcpe_rly set a_ ME= 1. Lenc'r_n recu-irW 2. Dist=.nce to wit= Tccursa maas-.r-d ft. 3. Installer acc —rdinq to plan 4. Distance centaT to center I 5. Sloce of tre_rc_n acceptable 1/16 - 1/32 " /foot. I 6. 10 feet f_an orcce_rty line - 20 fe_t - four =z-i cns I I 7. Depth of t_a^_cn < 30 inc:-ies free szar =ace i I 8. Roan allcwed for e-xnansion, 50% I I 9. Size of gravell 3/4 - 1i" di -met_r I 10. Depth of c=avel in trench 12 "' miniman -11 - Pig I I h. PU;2 OR DOSE - sfSm-m-s 1. Size of p= ch,--rber 2. Overflow taiLk I I 3. Alarm, visual /audio ( I I 4. Erna easily accessible rcanhole to grade i I 5. First box bGf =led i I 6. Cvcle witnessed by Eeal h De rtie_nt I estimated floe par cycle ( I HOUSE a. Ecuse loo =ted per approved plans. ( �C-J b. NLZnie-- of be rocns I I WELL a. Well located as ne*_' amoroved r)lars b. Distance fran SDS ax-Ea measured ft. I I c. Casing 18" above Srade_ I d. Surface drain ce around well acceptable. GVERAU WORFoZPS14 P a. Boxes proper-ly crcuted I b. A11 Tres partially bac_kfilled c. All ipes flLLh with inside of box I� d. Bac fill material contains stones < 4" in diameter- I r7 e. Curtain drain insta-lied accordinq to plan „ f. O.z-,ain drain cut =all protected. & dir.to esist_wat.= =urs�::l I- I - 11 lj� 11, g. tCCLLnq eras.,-zs e15=1k ce away =run -3uz3 are+ h. Surface water protec-ticn adeq uate i. E =csion control vrovided on slopes grert_r than 15 %. • YJ •fl�sf'� RHODESystems Inc. F� t Departrrnxit of Health Division of Environmental Health Services .Two County Center Carrel, ,.NY 10512 Re: the enclosed permit to construct :a water well Roger Rhodes, Philipse Brook Road, Garrison, NY Tax Grid 23 -5 -1 -1.12 Please advise as to the procedure for extending the expiration of this permit. I have just .engaged the services"of a well- dkiller and would like-to proceed as soon as possible. Thank you April 19, 1988 O Box k 0 f a DEPART;IENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPT,T -ATIQN -TO CONSTRUCT A- WATER••..WELL PCHD PERMIT # WELL LOCATION Street Address Tow4 Village City Tax Grid Number WELL OWNER N e. , Addr ss Mrivate O Public USE OF WELL 1 - primary 2 - secondary C"ESIDENTIAL ❑ BUSINESS 13 INDUSTRIAL ❑PUBLIC SUPPLY QAIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY OABANDONED ❑ OTHER (specif ❑ AMOUNT OF USE YIELD SOUGHT S gpm /# PEOPLE SERVED �0 /EST. OF DAILY USAGE REASON ..FOR .DRILLING ff1tv SUPPLY ❑PROVIDE ADDITIONAL SUPPLY O REPLAC EXISTIN SUPPLY ❑ DEEPEN EXISTING "WELL OTEST OBSERVATIOr DETAILED REASON FOR DRILLING �- WELL TYPE ILLED DRIVEN ODUG GRAVEL OTHER IS WELL SITE.SUBJECT TO FLOODING ?. YES "NO IF WELL IS .LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: H4E (T -AA-4j 0 I=•`� Lot No. WATER WELL CONTRACTOR: Name t--c� Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES E40 NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO-PROPERTY.-.-FROM NE.4-FST.WAT.ER MAIN: 7. LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ,r ON REAR OF THIS APPLICATION JL7J 29 (date) PERMIT �el ; AF�E (signature) 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. J 3.. Submit a Well Completion Report on.a form provided by the'Putnam County Health.Department. Date of Issue: dee_.e.twf'' 4 19 , ,.... _:-{ .....:....._..._. :. ; �... Date of Expiration � CC. -Al' st', ti 19 ermi t ssuing ffi ci al Permit is Non - Transferrable 8/86 —PUTNAMU COriUNTY ph e ivision of EnwronmeniaJ J, -f',CO'N.ST CTOWPCRI .0, iT FOR SEWAGE ;DISPOSAL L? A .Q­ A47, -A Ty Y Aide0 ' resign - -vp, separate Sewerage System to c'7oinsiitof yTObe et d 0 ttT e—M." Al upplyi! Public Supply From �_ 'e drilled b-, ::bj,,. P ovate Supply to -! r t -7- Address:; ,z ther.LRequ 1jer'nentf., –S I ys repyesLen t that I am•Wholly above 6nthe a pprov6d�5ftii6din, ,- County .Department oi, .` 4ea h;",an _ that on'; completion pp e,4nd a wrttgn gyarap t je-will : b Cf _place in` goof opetatpg- cor diti6na�y .0�rj of sewage' tlisposa o f the approval 'of-6e-6riifjcati,of 6onitriuctic;n do;m`li` r twill as--sho,.,w-n.lon,the.approiod' plan ,'ak-c'ih:ai said 'well `Lwill-bi " CoUhty' o Dipartmen Hftl th ' j t7 v Address W.i , ,APPROVED. FO R:CON TRUCTIOW; TKi'stiDok),Al �6)iDiies,one,veir' Date ,gy ­q "T V ie'*: date: Issued unliei IM%, me . i"F� .� � ff . UrAi" V ...... ...... Town or Villfga T F!c�vis ion . sus rov If :ffi`dT, bv-, 14 Y V stems) ,;,' that the. separate sewage, disposal system �,tliejdnjirdi-, rules•and regulations qf anee,",46i7fl-cioryA6, 66 Commissioner, t. w i, )helrSLP,!,.Wigns;6y- the'.`iiuiider, ' , that said Said builde' r will (2) years following the data oflhe lssu- �L !k*r!,_I iw2I h e drilled well describeci above ?sta rds,.,: a an .regu a s. , of ,the Putnam on R.A. JQL. license Fnte No tiuction of the building has bosh. undertaken and,,is t Health ,Any Chang ';>alteration,oi const. Title