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Home My WebLink About3052DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.25 -1 -25 & 62.25 -1 -26 BOX 25 No Il 9 Is ,. ~ ..'ti . . 1�. . hills T J ■ It �L L .' '- : �'I' , ,� wi. 03052 DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 _. _ .. .. ....rte....:. •_ -__.- . :_ �, , �..:.. �, ... •�m..::.M:: - a...:: -r, _. . - "- APPLICATION `TO `CONS'T 'RUCT ••P;- WATER WELL � PrWn PRRMTT 4 / 1/ � A Q WELL LOCATION Street Address Town/Village/City Tax Grid Number Ladd Lake Front ' Lake Oscawana, Put.Valley 10579 Lots 5. &6,Map 34 WELL OWNER Name Rita T. Eston Mailing Address CjPrivate 85 Windsor Terrace, YonkersiNY 107010.-Public USE OF WELL 1 - primary 2 - secondary Of §RTTIAL 0 BUSINESS ® INDUSTRIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP 0 ABANDONED O FARM O TEST /OBSERVATION []OTHER (specify b INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED -9 /EST. OF DAILY USAGE pd gal REASON FOR DRILLING NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY 0 TEST OBSERVATION OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL DETAILED REASON FOR DRILLING This is a summer residence (weekends & v c i by a seasonal water system Hiawatha Impr. Co whic costl more eo le re witching to wells. Will eve WELL TYPE ®DRILLED . []DRIVEN DDUG DGRAVEL ® OTHER r1 IS WELL SITE SUBJECT TO FLOODING? YES __.X�_NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: o• Lot No. WATER WELL CONTRACTOR: Name' Norman Anderson, Inc. Address: Barger St, Putnam Vall IS PUBLIC WATER SUPPLY AVAILABLE TO.SITE: YES __NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY ` DISTANCE TO PROPERTY FROM'NEAREST "WATER-MATN - LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION 0ON PARATEESHEE (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. 2. 3. Date of Date of Permit 2/87 Pump the well until the water is clear. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit.. Submit a Well Completion Report on a form provided y the Putnam County Health De artment. Issue: 19� Expiration: 1g Oefmit I suing fficia is Non - Transfer able White copy: H.D. File Yellow copy: -- - - Pink Copy: Orange copy: Owner Well Driller CAW ` WELL UlJMYLh"11U1V ttr.ruA.1 DEPARTMENT OF HEALTH > Dlvisi ,n-. -Of- En ironm _nta1 Healt-b .Serv_ices.___ PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only EET AD TAX GRID NUMBER: °' a WELL LOCATION WELL OWNER N ADOR 1141 PUBLICS ESIDENTIAL ❑ PUBLICS PPLY ❑ AIR /COND. /HEAT PUMP OX ANDOP ED BUSINESS D FARM ❑ TEST /OBSERVATION D OTHER (specify) O INDUSTRIAL 0 INSTITUTIONAL ❑ STAND-11Y D USE OF WELL 1 - primary 2 - secondary MOUNT OF USE YIELD SOUGHT � gpm. /NO. PEOPLE SERVED � % EST. OF DAILY USAGE gal. REASON FOR DRILLING NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY D TEST /OBSERVATION REPLACE EXISTING SUPPLY. ❑ DEEPEN EXISTING WELL DEPTH DATA I WELL DEPTH ae® ft. STATIC WATER LEVEL AL-L ft. DATE MEASURED DRILLING EQUIPMENT OTARY ❑ COMPRESSED AIR PERCUSSION D DUG ❑ WELL POINT ❑ CABLE PERCUSSION D OTHER (specify): WELL TYPE D SCREENED ❑ OPEN END CASING. OPEN HOLE IN BEDROCK 0 OTHER CASING DETAILS TOTAL LENGTH ft MATERIALS: STEEL D PLASTIC O OTHER LENGTH.BELOW GRADE It JOINTS: D WELDED WTHREADED O OTHER DIAMETER in. SEAL: D CEMENT GROUTbBENTONITEkdLT0THER WEIGHT PER FOOT — Ib. /ft. DRIVE SHOE: YES ONO LINER: ❑ YES NO SCREEN DETAILS ... DIAMETER (in) 'SLOT SIZE LENGTH (It) DEPTH TO SCREEN (IQ DEVELOPED? FIRST _ ....:.. HOURS SECOND _ ..._.. _ _ . GRAVEL PACK O YES O NO GRAVEL SIZE.. DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST 11 If detailed pumping METHOD: O PUMPED 1 tests were done is in- COMPRESSED AIR , formation attached? O BAILED O OTHER i O YES ' ONO It more detailed formation descriptions or sieve analyses WELL LOG are available, please attach. DEPTH FROM SURFACE water Bear- ing Well Dia" meter FORMATION OESCAIFiION CODE. ft. ft. WELL DEPTH It. DURATION hr. min. DRAWOOWN R. YIELD 9Fm. Land Surface /� (® i, WATE$ -CL€AR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY ,GAL. PUMP INFORMATION. �/ TYPE CAPACITY MAKER DEPTH �� ®� MODEM I / VOLTAGE WELL ORILL AME DATE AooRESS�S ° rDZiORE V . — ,_ � y 1 I e (il 1 till ' o ! ® •S� Pric �ErI .. I 1 a i V �., v.. �'.N.w:......rcw•i. K.u.y::..";+.�::. :.. _._:_..._._.. '..vn. .. - .�.. v.. r. ..,..._ a.': L,..s -, 1. Km..a.w �yvN..r+.�:_ .. _. - `x,_.i.,_v.: _ .. �>R ^.- w. Rita To Estony 85 Windsor Terrace Yonkers, N.Y. 10701 October 7, 1987 'RECD VEC Putnam County Department of Health Division of Environmen 1 ea th Services 110 Old Route Six Cent.4 � � ° P 1 :34 Carmel, No Y. 10512 Attention: Chris Johnson Dear Chris: In accordance with our telephone conversation of this date, I am herewith enclosing for your records my Well Completion Report and the Laboratory Report on the Bacteriological Quality of Water. As everything appears to be in order, I have now put my well in my residence in Putnam Valley in service. Encso Thank you for your cooperation. .Sincerely. yours, Rita To Estony Yorktown .Medical Laboratory, Inc. 321 Kear Street Yorktown Heights, N. Y. 10598 - Director: Albert H. Padovani M. T. (ASCP) T_ LAB # Date Taken: 4 /a % Time : J�' A- -Date Rc'd• 7 Time: - ..-:.. -..... ._ , -..�. Date Reported`: Collected By: %J ✓lbcllure� Referred By: Sample Location: D Phone N Phone # Sample Type: Repeat Test? _ 1(check one) LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER GENERAL BACTERIA Standard Plate Count (CFU /.1.OmL) (Agar Plate @ 35 °C) MEMBRANE FILTRATION TECHNIQUE (MFT). V Total'Coliform (CFU /100mL) Fecal Coliform (CFU /100mL) Fecal Streptococcus (CFU /100mL) MOST PROBABLE NUMBER TECHNIQUE.(MPN Total Coliform: MPN Index (per 100mL) -: -Fecal Coli-form: -MPN- In -dex (per` lOOmL)- OTHER ANALYSES REMARKS (For Laboratory Use) E Potable Non- potable STp TNF _ STP EFF Other: Sample Status: (check each) Outgoing Na2S203 Incoming _ ✓LE 4 °C GT 4 °C Other. KEY FOR'TERMINOLOGY RDS = Recommend Disinfec- tion of Source TNTC= Top Numerous To Count CON = Confluent ( =TNTC) LE = Less Than (C ) GT = Greater Than ( >) N/A = Not Applicable THESE RESULTS INDICATE THAT THE -WATER SAMPLE (WAS) (WASN'T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO TH NEW ORK STATE DRINKING WATER-STANDARDS, FOR THE PARAMETERS TESTED, AT -TEE TIME OF COLLECTION. /x/ VJ 1 Albert H. Padovani, M.T. (ASCP), Director 12 /E5(Rvsd7 /87)RWE For Lab Use Only: H/C to LAB OFFICE HOURS (Main Lab): 9AM -51M, Mon. -Fri. 9AM -NOON, Sat. PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Commissioner of Health NAME ADDRESS f - FIELD ACTIVITY REPORT - Sheet of No. Street Municipality (T)(V)(C MAILING ADDRESS P.O. Box Post Office Zip Code TELEPHONE PERSON IN CHARGE OR INTERVIEWED Name and Title l I le DATE' TYPE FACILITY TIME ARRIVED TIME LEFT INSPECTION Orig. Routine Orig. Complain Orig. Request _ Compliance Complaint Comp _ Final Group Illness Construction Reinspection Field, Sampling Only Field Conference Other Explain INSPECTOR: ture 'and Title PERSON IN CHARGE OR INTERVIEWED: TELEPHONE: I acknowledge receipt of a copy of this SIGNATURE: Field Activity Report.......... - - ... TITLE: f� .. YID- '•..Y; ),ixv .1., .., .y _...' 11 '...� �� .F '4V N' • � i. ..�. ,..: x3:{"'.t: �,rs,�9'.t,•.' -a .i �d;h3a1 -?� ii" u• =5. r :��,,`;J -,a w.s5_ .'7 �. r �.. r� w�.:✓ L°-��. tu, ". -,.:. �'3 ;' l'.+ �: '� '� '. WELL LOCATION WELL COMPLETION REPORT DEPARTMENT OF HEALTH i.a;�gr>L.0t AjFpRmenta'l Health _.Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only W GRIO NUMBER: j WELL OWNER N�ME� ,� 6 ADD f ssO / rte,, (/�,�i '-�] r., � PUBLICE ❑ NO I SIZE WELL YIELD TEST If detailed pumping USE OF WELL 0 RESIDENTIAL ' ' ❑ PUBLIC S/IPPLY d ❑ AIR /COND. /HEAT" PUMP ❑ 1 - primary rY '❑ BUSINESS ❑ FARM '❑ TEST /OBSERVATION JABANDONED ❑ '6T HER HER (specify) 2 - secondary ": ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF -USE YIELD SOUGHT gpm./NO.•PEOPL'E?)S2ERVED / EST. OF DAILY USAGE gal. REASON FOR �O NEW SUPPLY D PROVIDE AO()ITlOUAL SUPPLY ❑ TEST /OBSERVATION DRILLING 0. REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA EPTH _)_400 f f 2 , O :. .. DRILLING EQUIPMENT WELL TYPE CASING DETAILS SCREEN DETAILS, _ WELL. 0 t. STATIC WATER LEVEL ft. DATE MEASURED `i 7 _.ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT, ❑ CABLE PERCUSSION ❑ OTHER (specify): O SCREENED ❑ OPEN END CASING. ,Q OPEN HOLE IN BEDROCK ❑ OTHER TOTAL LENGTH 2 / ft. MATERIALS: 'd STEEL O PLASTIC ❑ OTHER LENGTH.BELOW GRADE /� .1�. JOINTS: O WELDED ,WTHREADED ❑ OTHER " DIAMETER in. SEAL: ❑ CEMENT GROUT ❑ BENTONITEK[ OTHER WEIGHT PER FOOT lb./ft. DRIVESHOE;'0`YES ❑ NO UNER:0 YES �INO DIAMETER (in) SLOT SIZE LENGTH (1t) DEPTH TO SCREEN (it) DEVELOPED? IRST rnn:fn •. ..�. -..., ... - .._....�.... ... ___ __ ..._ .._ . . _.: O ;YES -.ONO �.,:.... GRAVEL PACK ❑ YES GRAVEL ❑ NO I SIZE WELL YIELD TEST If detailed pumping METHOD: 0 PUMPED tests were done is in- &gOMPRESSED AIR ; formation attached? b- BAILED ` ❑ 10THER ; ONES: -'O' NO WELL DEPTH DURATION ORAWOOWN YIELD It, hr, min, ft, gFm. WATER -d-CLEAR TEMP. QUALITY 10 CLOUDY HARDNESS 0 COLORED ANALYZED? O YES ONO ANALYSIS ATTACHED? O YES O:NO PUMP INFORMATION r. TYPE ? CAPACITY MAKERj, 0 /;6-_, DEPTH Ze d j MODEL VOLTAGE L �L H HOURS DIAMETER TOP BOTTOM OF PACK in. DEPTH ft. DEPTH ft. WELL LOG �f more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM Water Well SURFACE Bear - ,OIa- FORMATION DESCRIPTION rAOE. it., " 4L mg eter. In iurtace 1 / � �� AJr .�'E..- `�= •Q— r`-- •- --"'." - �'� �G•e -mil_ STORAGE TANK: TYPE_ CAPACITY WELL DRILLE�RR.' AME ADDRESS 'X - ,. GAL. DATE I