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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.10 -1-41 BOX 28 I ru NJ I 'I 61 mo , rh, i 61 �'!:} 03616 PUTNAM COUNTY'DEPARTMENT OF HEALTH - DIVISION_ ,OF .ENVIRON_ MENTAL HEALTH- SERVICES..: - - _ rep'.S -M . �,f?„yC - w- r- •Ip- �`ii14" tTr. -:9w, ..�.J'l �: :�f R`•::.,r...r. - A n+ �r.> �R)n.. ^a: rf .e .. - - .rr.�• - r•'t!!.r♦ ti't!� -..i. "' �-r :'K w•• r�'r.. �.I'•.:. .r n w CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SE _ WAGE TREATMENT SYSTEM �r PCHD CONSTRUCTION PERMIT # 3 - c ..: 5 Located at /9'/ , �frz - e-r Town or Village 7 Owner /Applicant Name Tax Map /� Block _� Lot Formerly Mailing Address /—�p ge" Date Construction Permit Issued by PCHD Subdivision Name Subd. Lot # e4 Separate Sewerage System built by Address Consisting of / L, Gallon Septic Tank and Other Requirements:t� ley Water Supply: Public Supply From Address- or: Private Supply Drilled by All/' Address O L' ,�C�° ;_ _ ' Has erosion control been completed? � j ' Building: Tyne :_ r��z -:y_� __�._ t . Number of Bedrooms .14-1 Has garbage grinder been installed? A c� 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 regulations of the Putnam County Department of Health. Date: 2-1 a e V Ce rye . ,''� / / �°� P.E. R.A. esi n Professional) Address'% License # An erso ,o�J em `" Wo�vll /Slysi em s shall rom tl take such action as ma be necess Y P q PYmg P ry �' () promptly Y Y necessary to secure the correction of an rtions resulting from such usage. Approval of the separate sewage treatment system shall become n �. 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 revocation, modification or change is necessary. By: 'l Title: Date: L&' /()I/ White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM CO1UNTY DEPARTMENT OF IE][1EALT}H[ DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT e taon Street res : T Tax G Map Block / Lot(s). 1 Well Owner: e: Address: Use of Well,: 1- primary 2-secondary �idential Public Supply Air cond /heat 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 _/'<�. Open hole in bedrock Other Casing Details Total length �ft. Length below grade refit. Diameter to ` in. Weight per foot alb /ft. Materials: �_ Steel _ Plastic _ Other ;y, Joints: _ Welded Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: Yes _ No Liner _ Yes 5-,, 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 Hour Yield k_, gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve.ariays�s _. are available, please attach. Depth From Surface Water Bearing Well Diameter(in) )Formation Description ft. ft. Land Surface ®b 6 K _ :._ :: � .. .. _... -� - • " — __ .......�. _ ...Y . r .. . _ ./ _ - :..:_ .., .: .... .. _ If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity e. Depth ZeO Voltage v HP.j Tank Type O So Volume I 4 7 Date Well Completed Ill lt)3 I Putnam County Certification No. I Date of Report �/5 1", ell Driller (signature) I nu!i m /exact location of well wttn aistances to at least two permangnt la/mmarxs to be provided on a,separate sheettplan. Well Driller's Nam�.Lt Address /�7�� .? Date: Signature: °� - � ids White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 )3RUCE` R. FOLEY LORETTA 214OLIN.-tRl Public Health Di I -ect 0 1. Associate Public Heol!h -Direcear of Patfznr DEPARTIMENT-OF- HEAL7' Geneva Road Brewster, New York 10509 Liwiroximentut I-Icalth (91,4)278-6130 Fu (9111) 278 - 7921 Nursing Services (914) 278 - 0558 IVIC (914) 278 - 6678 Fax (914) 278 - 6085 Endy Intervention (914) 278 - 6014 Preschool (9)4) 278-6082 Pax (914) 278 - 660 1 E911 ADDRE'SS VERIFICATION FOR CPAINT'A'tS NAM..E: TAX NIA PINT I NIB E R: U1191 t ADDRESS- 1`0W IN: ZZ,7- /--D '1� ---- ---- -- JD- (SIgneature.) MIT,: J 4 `.f'he Puttiam COIR.Ity Department of Health will ti.ot issue a Construction Cot , ripliance unless the above form is completed, i.e- L address is assigned by an aUtII0I'iZC(I tOW11 OffilChll. This form is tC. With the IPPIjUltion fora Certificate of Construction Compliance, I VI:; PUTNAM COUNTY DEPARTMENT OF HEALTH[ DIVISION OF ENVIRONMENTAL HEALTH- SERVICES..- -...: GUARANTEE DE SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Building Constructed by Tax Map Block Lot TownlVillage eJ Location -- S.-treet Subdivision Name 1 1 Building Type Subdivision Lot :4 I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the 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 thel'utnaciCounty I)epaYtment oiKea�th, 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 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 tht oVA ngu0iimgthe 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 V\ XXungut�l�ti�ngthe system. Dated: Month 2 Day J Year e7 General Contractor (Owner) - Signature Signature: _ Title I' r e. 5 Corporation Name (if corporation) Corporationl�ame �if co�poration� r Address:ljC�'���%� /3�. Address:��'.� State Zip / % State Zip Form U_91 ' YML ENVIRONMENTAL SERVICES 321 Kear Street Yo�ktp��) Y��1O598.`,���'��__'' (9'14'/-245�l�800 Albert H. Padovani, Director LAB #: 32.400444 CLIENT #: 12591 NON STAT PROC PAGE: 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ p~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MJD CONTRACTING CORP. 1992 COMMERCE STREET YORKTOWN, NY 10598 SAMPLING SITE: 264 BARGER ST : PUTNAM VALLEY NY 10579 COL`D BY: BEN COZZI NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE PUTNAM CNTY 01/20/04 01/2O/04 01/20/04 01/20/04 01/20/04 01/20/O4 01/20/04 01/20/O4 01/20/04 01/2O/04 _. 01/ DATE /TIME TAKEN: 01/20/04 01:00P DATE/TIME REC'D: 01/20/04 02:36P REPORT DATE: O1/27/04 PHONE: (914)-245-(�880 SAMPLE TYPE..: POTABLE VES: PRESERVATI NONE TEMPERATURE..: < 4C COLlFORM METH: MF � ... ... ... ... � ... ... ��. RESULT NORMAL --- RANGE METHOD PROFILE MF T� COLIFORM ABSENT /\00 ML LEAD (111S> <1 pp b NITRATE NITROG 1.98 MG/L NITRITE NITROG <0.01 MG/L IRON (Fe) <0.060 MG/L MANGANESE (Mn) O.016 MG/L SODIUM (Na) 41.7 MG /I... pH 6.6 UNITS HARDNESS, TOTAL 186 MG /L ALKALINITY (AS 98.0 MG /L -_TURBIDITY (TUR <1NTU -' ABSENT 0-15 ppb O - 10 N/A 0-O.3 mg/,l O-0.3 mg/l N/A 6.5-8.5 N/A N/A . 0�5'NTU COMMENTS: BACT THE RESULTS INDICATE THAT THE WATER AS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIN���ll.�HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS; FOR THE PARAMETERS TESTED,, AT THE TIME OF COLLECTION. Pb /Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. _tblic schools are set at 15 ppb. Rule for Public Systems requires that no more distributiun points have at LEAD v4--.7t1ue of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed O.5 Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. 1008 9101 9139 9146 2037 2O37 YML ENVIRONMENTAL SERVICES 321 Kear Street ' - (1?14) 243-2800 � Albert H. Padovani, Director LAB ON 32.400444 CLIENT #: 12591 NON STATPROC PAGE: 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MJD CONTRACTING CORP. 1992 COMMERCE STREET YORKTOWN, NY 10598 SAMPLING SITE: 264 BARGER ST : PUTNAM VALLEY NY 10579 COL'D BY: BEN COZZI NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE DATE/TIME TAKEN: 01/20/04 01:00P DATE/TIME REC'D: 01/20/04 02:361-` REPORT DATE: 01/27/04 PHONE: (914)-245-0880 ' SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD PH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH [S 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 O TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 3OMG/L EL�(N 1Y) 14O ANk- HARD WATIA-,:-�4�-����/^���/��--''^---^ |��/g�l^|6n- LAW- 11G/[1~-'------ SUBMITTED BY: Albert H. Padovani, M.T.(ASCP., Director ELAP# 10323 t.-%T%,m T- r, ev PUTNAM COUNTY DEPARTMENT OF HEALTH -.,.---J)IVISIONO-lr!E.NVIRONMENTALlfEATLITSERVICES FIELD ACTIVITY REPORT Zz--, 1 Street T I own State Zip PERSON N CHARGE T)Ate. ng iNTF.RVfFxAm-T). PUNT TEST E DOSE TEST Vol TEST Fl- START EL. STOP lWSPF.rTQP! TF.T! Sioature and Title RFPQR I tFrF.TVFn R-yr., I acknowledge receipt of this report: SIGNATURE: 02/96 Title: i 0 I 7-1 1_ t it _21 if If =4 BR_ENI`SHL(_,GEOdF .,CNAHIR. it 7'_ il';' Sr --E VALI Till if -41 Z:': 7- i� 1-T, d l���ig,,��iMEPL,�rL3rL3rL3r3dL3rL3 11 3r3 r3p P, rL3j"L3,[ _p j`LpfflL r Lj`gg QgMpL@3rL3 pj:..M E 0: FJ'FC- -,--Ei:�0,F:L'C-O.MRL-,I.ANC,EiiTH, E-,ijlj H_�Jjlj _AR -DE F 1- If= -C REA 'ST1 HNEW ti REE-T=-f ;IYO' !J6 _0 I � ILL !�!L7 t _L!� it'_ f .,-,-�-C�.ERTI'Fi�E'S.,-i�-THATI Z-1 g— il-upon prernMS- oWhe'd-by:=-_) icatiOn, In z L it F= if 290MILSON-RU11-11, It 2 � �A, B EM S T E R--, N - - 1 5 H =A. �7- 1 Y 1 "0579 T1 I I i Located-tati 264'BRKUtrj,')'1 J.r-Ull I%JMIVI:--V/ALLI T F-Lil _-T 1 _'7 EL if 1 €190f7 2-7 '. I 'o . 'i ", -19072, i ca e- it d" Section L6 - I . 1 -1. , I , , ', 12 9-1.0 4- sr it �q .. .... -7, 2- j --H d'' oc'cUpanby,',-:'whe "i i s��! e I e ri I- consisting of- .remises S-8t.-T devie, -es. and Wring; _d6kr bed ,dJn/'6n,..th6_p i�6 11'I Z_ j 7 46' -61 'e n t-ji, 0 t 1 d T41 -ti it 'tH I- T j _2 j. 3J `it li i3 _H' 2 Ti 1 t ilm atiphalliectricalG6 installati �was - inspected ih-6c.-c--6rdan-c--ci�with,-the' ail" t l.-- L I found'to be --in'-c-ornplianc therewith 'Ta . LTH'tM.-u, Y'OP-_ - .1, - Yr. r "IN C. Ratin L4 i-z' mmillithleous-, It -T F-SEPTIC TU, IMitAND !NG-E) 7:' 17' - J_' -_–Jizz =p -T L-IT J JL 21- nVt it 7 i T-21. IFF;i 'Al t if I'l. t, J! I i it 1, if lt zr- t if ....... . . . it T-N 7!L ept� �i _j, 71. j, It �a -7 YiD.Y.Ane-presenceof ral I Jn is-. ci5rtifii:Eit67May not-,,i)eiaite,c�-e,.a�!-in-l�-a;ns-�y�A,---w-�"a-,y,�anaiis-vaiiaated,,Oni- he., ocation if !Pffl@rr@@�EZI 1911. ffL3rfflpL'M'@PLfflrd3 -LJJRPLrL3pLrL3rL3pLrL3rL3rL3FL3rL3FL3rI 11 " it I if 01/07/2004 07:59 9149624248 JOSEPH SULLIVAN PAGE 01 PUTNAM COUNTY DEPARTMENT OF HEALTH. DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION GENE FOIL ENALINSRECTIM For: All information must be fully -completed prior to any inspections being made. Fill Trenches PCBD Construction Permit # J,3 — ov )e-, Located: Q4 Owner /Applicant Wame-/4r_P_4,, , (jC0=_4_/-2 TM 74,1 Block -1 Lot Formerly: Subdivision Name: !ZA E.M .4 -ey Subdivision Lot #____ Is system fill completed? Date:- Is system complete? Date: _- Is system constructed as per plans? Is well drilled? Date; Is well located as per plans? Are erosion control measures in place? I certify that the system(s), as Wed, at the above premise's has been constructed and I have inspected a4d verified their completion in accordance ' with the.,issued PtHD Construction Permit and approved plans and the Standards, Rules and,Regulations of the Putawn County Department of Health.. Date: Certified by, czvl_�14 FE RA Design Professional Address: Lic. 9 Comments: /'7*, op?_ Form FIR-99 JAN-7-2004 WED 09:30 TEL:845-278-7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 .01/08/2004 12:20 8455283024 PAGE 01 / 134 e L IV L Yo �r c (f/,S r,7—,! C O—r-,5— � A te. S �r 6 c S~ �v ri 01/08/2004 12:17 8455283024 Ir-J-0 CA tK PAGE 01 KIOMP • PI ITNLIM rni INTY nFPAPTMFNT OF P. 1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENViRON1VI FNTAL HEALTH SERVICES FINAL SITE INSPECTION Date: S I % i c'3 Street I ►cation �, �- S °"�`� Owner--:' va per =. , .N _ - Inspected b TS P :.:p ec Town AW. Permit # ) 3 a p TM # 7 �1, j Subdivision Lot # sc, E's47.1es Lof + S 1. 3ewaL�e Systeen Area a. STS area located as per approved plans .......... .. ................ 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......:... e. 100' from water course / wetlands ...... ............................... ID[. ma,e Systean a. Septic tank size - 1,000 .... ..... 1, 250 ..:......other ................ b, . Septic'tank installed level ................ ...... .......................... C. 10' minimum from foundation .......... ............................... d. ]Distribution Boxy 1. All outlets at same elevation -water tested .......:......... 3. Protected below frost .................. ............................... 3. ..Mninium. 2 ft. Original soil between box & trenches e. Junction Boa - properly set .......... ............................... 6. renc hes 1. Length required Length installed & 7 2• Distance to watercourse measured Ft.: (,{ ;. Installed according to plan......... . .. ............................. 1. 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 .................. i. Room allowed for expansion, 100 % ......................... 1. Size of gravel 3/4 - 11/2" diameter clean ...................: a. Depth of gravel in trench 12" minimum ....... :........... 1)..Pipe ends ca ed... .............. g'• ' r�arnD or Dose Systems i. Size of pump chamber ............. ............................... �•l�OveFflow ta3ik.::: �:� :...................... ............................... ci warm visua) dio..::: ...:................ .1�c ..�r.,. �3 s... 1. Pump easily accessible, manhole to grade ................. ci. C, cle'witnessed by H.D.estimated flow /cycle..`.? w, IID[. IE�I��e/B'uildiri�--- _.__.___.._ . �. ..__...------------ __._- -� -�- -_ a_ -louse located per approved plans .......................... b Number of bedrooms ........................ :.. r. :a. IV.. W d .., 1: A Well l;�ated as per approved plans . ......:........................ b. Distance from STS area measured `(0 0 ft........... _ rasing 1$" above grade .......:........ .............:................. d. iurface drainage around well acceptable ....................... V. ®wTaZ 'Yorkmanshi� . a.- 3 oxes properly grouted ................... ............................... b _ :ill pipes partially backfilled ........... ............................... c- X11 pipes flush with inside of box ........... ... ......... . .......... d lackfill material contains stones <4" diameter .............. e _ Curtain drain & standpipes installed according to plan.. E Curtain drain outfall protected & dinto exist watercourse E9 - Footing drains discharge away from STS area ............... b:- .3udace water protection adequate ........ :........................... i- erosion control rovided ................. ............................... Rev, ?2r/002 vi Au COMN ENTS ZIZIL 10 r9s r ty M44A Lr.� VIZ- LZ Form _ .-, ?e ./ -Z.._ •11/04/2003 11:06 9149624248 JOSEPH SULLIVAN PUTi AM COW ,, DTI[ OF rr�rizzo u 3ado = im =a be Oft opw*sd prior a �► srrtw= b4* ulmw- CHD Comractim Permit # �/of VftwIAWcaat Nam.: par n�..� r..... �r /rli,-Pg �- 3 eysama filu 00OPWOR A .x DOW #..... �.�« (s wa " mom? An avd= cc*d 1l iRtlgt tad v � � �u #r�d� �$1+I�w�• . i . ,........ �_. �e� erm t� ccl is approved pbm iW tine $mole* NW. � �r. c>�,• 1. Dft 3_ Coiidd Form FIR -99 0 wn 1- 4 -PSM7 TI IF 1 a: 7A TFI : A4S- ?7A -7gPl PAGE 01 NAME: PI ITNAM mi INTY I•IFPARTMFNT nF P. 1 r d" DM510-N. .OF : IENWRONMENT:A1L.HEAIL7I'IHI SERVgCES.r. CONSTRUCTION PERMIT MIT FOR ;F�c�IE.: �' , ATIVITIENT SYSTEM PERMIT # Y - 3 -173 S Located at &t- j y,� , Town or Village � !!.-h /% &4 Subdivision name AAubd. Lot # ;--5 Tax Map Block / Lot / Date Subdivision Approved //:?-// % Renewal Revision Owner /Applicant Name AIIJ I-2 Mailing Address /�'' Ye, ),,f; 4 ej"7 Amount of Fee Enclosed .0 Date of Previous Approval. - LCI f Building Typed Lot Area s No. of Bedrooms 4 Design Flow GPD Zip ]Fill Section Only Depth Volume PCIll1E[D NOTIFICATION IS RE >L IREEIlD WHEN ]FALL IS COMPLETED Separate Sewerage System to consist of 5 4.1 gallon septic tank and Z � Other Requirements: 1-41 To be constructed by 0 X--, Address 1 01w C Water -SuPx1 .:.._.... .,Public. Supply From... o1r: tx- Private Supply Drilled by j j /� r: Address 1�; r;, er- I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will 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 treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address APPROVE IFOR CONSTRUCTION' sewage treatment system has been completed and inspecu modified when considered necessary by the Public Health OF �NEW R.A. Date Z --o �-1 e License # -7 y from the date issued unless construction of the and is revocable for cause or may be amended or revision or alteration of the approved plan requires a new 7it., Approved for discharge of domestic sanitary sewage only. 5AV- P /j , 2 f By: , Title: �- %v► /��. Date: C>? opy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL arinc (f,°m» PCHD Permif # �� - >... _..... Well Location: Street Address: Town/Village Tax Grid # Jke e-¢ .AvIll1ofitt # -Y Map 7 *./ Block i Lot(s) 41 Well Owner: Name: �* / Address: j r wzl 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 gpm # People Served _ Est. of Daily Usage rc7ci gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling d -New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ........................ Yes No ice_ Is well located in a realty subdivision? ...................................... ............................... Yeses No Name of subdivision Lot No. Water Well Contractor: Address:��'���'.�%r'�i'' Is Public Water Supply available to site? ................. Yes No Name of Public Water Supply: "' Town/Village -- Distance to property from nearest water main: "A-0 Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: j =3�� '` 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. 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 Public Health Director. 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. Q Date of Issue 7 l b Permit Iss ' g Official: I Date of Expiration 17 fc, Jv S' Title: 1i 14eJ44 - A—er — Permit is Non-Transferrable White copy - HD file; Yellow copy,- Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 ." 74 . v -fit �1 3i L I "I'll?" 1',I� "MIN, ;:I�IL�� 1q'� j�p@[+ _ l,LL4R'll(S:;e pWjl . �:Yi2MI1c�:j�CG�A�W1��.,R�l ua 11 1H."I a cry: av aum mm n.s sw H. .l4M.v„InAn:ro�]nNr,.l:r11194.rf .rm9MRlf.Irm 1 NO �n 3A YN GPM GPH• y w Ft. Lbs. Ft. Lbs. Ft. Lbs. Ft. Lba. Fix. Lbs. j �FR._yl_ lbs. 1 60 4.25 1.85 1.38 .60 .356 .155 .11 .048 2 120 . 15.13 6.58 4.83 2.10 1.21 .526 .36 .164 .10 3 180 31.97 13.9 9.96 4.33 2.51 1.09 .77 .0 .21 :090 ' 10 1 .043 4 240 54.97 23.9 17.07 7.42 4.21 1.93 1.30 .565 .35r 150 16, .071 - V 5 300 84.41 36.7 25:78 11.2 6.33 2.75 1.92 .571 .223 �� 24 , .104 � y.309 6 360 36.34 15.8 8.63 184 169 1.17 .71 i .3-3 1 .145 8 480 63.71..27.7 15.18. 6.60 4.53 1.0 1.19 .3.._.'_...241 10 600 97.52..` :' '42.4 2526 11.27 .. 6,0- ; 2:99 1.78 .774 AS � .361 15 900 49.68 .21.6 14.63 6.36 315 1.63 i -1,74 �`�1.28 't :755 20 i 1,200 86.94 37:8 25.07 %9' 6.39 2.78 i 2.94 25 1,500 38.41 16.7 9.71 1 4.22 4744 1.93 30 I 1,600 13.62 W °.`3r VW6.2r; j W.72. W r 35 2,100 18.1.1 9C' 8,37. 3.64 40... 2,4[x0 ._.._ _ ' 23.5;i:.:. 1-10.24, .45 I _ 2,1!00 d _ _ 29.44 _ _ 12 81) � ; :x.46 5.86 - 50 3,(100 �i7. 715 60 3,600 10.21 1 ad U /c/ 1 0 ;:mss �tA � � � •'4 �V � � i�,� � c�S L� �Y3 &1� � 4.,� •� � \ I � � � � \/• � � g � •�A I 1 � fi �➢�RI� ��I T OF-ENVIRONMEN- 7�'A�.� IH��FA�.,T ..SERVICES LETTER OF AUTHORIZATION :l RE: Property of �4Z a Zit` Located at � 0 "� 1, T/V�/ le- ax Map # Y. / Block �_ Lot Subdivision of A /4% Subdivision Lot # :51� Filed Map # 2�/o Date Filed ����s' Gentlemen: This letter is to authorize a duly licensed Professional Engineer t/ 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 connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in comity- wiffi-the pr- 6,iisions df Aiticle- -145 -- and/or 14.7. the.-Education Law, the Public.Healtr__:.._ Law, and the Putnam County Sanitary Code. Countersigned: P.E.,f., # — Very truly yours, Signed: (Owner of Property) d" Mailing Address: LILI � �G✓- State ';�' Telephone: Form LA -97 PROJECT 10, NUMBER 617'20 SEQR APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLI.STED•ACTIONS Only.'._ PART- PROJEc-T�INF�ORMATF N. � -_('To de-completed'b "y Hpplican� or Project Sponsor) 1. APPLICANT/ SPONSOR ' 2. PROJECT NAME x Y efe 3.PROJECT LOCATION:�� j�,rL� -L�.7 " Municipality �v. /✓l G'r,Y� f /J %j,�' // County 4: PRECISE LOCATION: Street Adclesss and R ad/ Intersections. Prominent landmarks etc or provide / map�.=.l �r �G; "l?T. � � J /.�G�: �4- � i✓ r��'� t� c� � /� J�f �'i!? ,��fr -" �i��L�yLi� /'' <✓� 5. IS PROPOSED ACTION: `� New Expansion Modification / alteration 6. DESCRIBE PROJECT BRIEFLY: / Kn1 f //fY }' G /t /./ / 4 jS j•!• ✓" fir+. 7. AMOUNT OF LAND AFFECTED: i Initially acres Ultimately acres ` : 8. NJIL_L kOPOSED ACTION COMPLY' WITH EXISTI G ZONING OR OTHER RESTRICtIOIVS?.. v /Yes a No If, no, describe briefly: 9. VYHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ,(Choose as many.'a§ "apply.) Residential Industrial Commercial []Agriculture Park /Forest /Open Space Other (describe) .. . 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY.OTHER .GOVERNMENTAL. AGENCY. (Federal,' State or Local) 17 Yes No If yes, list agency name and permit / approval: 11. DOES ANY ASPECT OF THE ACTION HAVE .A CURRENTLY, VALID :PERMIT OR „APPROVAL? ...... . Yes . ❑ No • If yes, list agency name and permit J approvak 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT / APPROVAL REQUIRE MODIFICATION? QYes IRNo I CERTIFY THAT THE; INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE �j Applicant / Sponsor Name I pip 7V �r� Vf' f� Cj Date: J z°3�`�� Signature----- -L7`_- - rte' - - -�e 3`' •/ If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before'proceeding with this assessment �..: ' PART!I - IMPA CT ASSES SN. ENT (f:z be.cnrnnleted:b/ Lead agency)-: A. DOES ACTIONAtEED ANY TYPE -1 THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. :.0 Yes No rgr; B,'Gkl_ ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN-6` NYCRR, PART 617.6 ?. If No, a negative' declaration may b superseded by another involved agency. 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 pattern, solid waste: production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: MCI> 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: 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 resources? Explain briefly: Mp AAf C5. Growth, subsequent development, or related activities likely to be induced by the proposed'aetiorr? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly: C7. Other impacts (including changes in use of either quantity or type of energy? •Explain briefly: s ' A/p7— D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)? (If yes; explain bricfly:�, _ Yes No �_T �,..:� E. IS THERE, OR THERE LIKELY TO BE, CONTROVERSY RELATED. TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If Yes explain: Yes 77 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 materials. 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 of significance must evaluate the potential impactof the proposed action on the environmental characteristics of theCEA. Check this box if you have identified one or more potentially large or signif cant 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 actin WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. ,i•tC � • .. �- Name of Lead Agency Date rint r Type Name of Re onsible Officer in Lead Agency Title of Responsible Officer i ignaLure of Responsible Officer in Lead ncy Signature of Preparer (If different from responsible officer) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENTSY$ TEM:•..._. �........ ... _t .... , Name and address of applicant: ." '1 A A 2. Name of project: 3. 4. Design Professional: 5. 6. Drainage Basin: 1,5e r �, el' �» L 7. T e of. ro'ect: . _ Private/Residential Apartments Office Building Location TN: Address: Food Service Institutional Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review'(SEQR)? Type Status (check one) ......................: ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... ° a/�/ 10. Has DEIS been completed and found acceptable by Lead*Agency? ............. .... 11. Name of Lead Agency 12. Is this project in. an area under the control of local planning, zoning,- or other.. officials, ordinances? ............................................................ .......................::..:... 13. If so, have plans been submitted-to such authorities? ... :............... : ............... :... }/ - 14. Has preliminary approval been granted by such authoritiesT `,� Date granted: t 15. Type of Sewage Treatment System Discharge ......:.......... surface water groundwater, 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) ..................:..:.................:... ............................... 18. Is project located near a public water supply s stem? ' cj 19. If yes, name .of water. supply Distance to water supply %:f J 20. Is project site near a public sewage collection or treatment system? ................ A/ ,:� 21. Name of sewage system Distance. to sewage system 22. Date test holes observed - Z.3, 23. Name of Health Inspector c¢o-:,.; t,01� 11Vfe Y! r� 24. Project design flow (gallons per day) ................................. ............................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... Ald 26. Has SPDES Application been submitted to local DEC office? ......................... Form PC =97 -27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number... ....................... ............................ ; ................ ....�....,.;. -- _. 29. Is Wetlands Permit required? .............................................. ............................... /I/o Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling; sludge application or industrial* activity? ............................ Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No 'DESCRIBE: 33. Is.there a local master plan on file with the Town or Village.? .......................:. . A/e 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope .. ............................... . 36. Tax Map ID Number .......................... ............................... Mapes Block / Lot 37. Approved plans are to be returned to ..... Applicant Design'Professional NO :.Al applicatiQnS:£or:revsFw and approval of a- nL;v -S S-ta be located within theA)'rC Water "shed shall be 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 ofa 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. If the application is signed by a person other than the applicant shown in' Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under° penalty of ter f urry, that information ppovaded on thisfo rM is true to the best of my knowledge and belief.. False statements made herein are punishable as a glass A misdemeanor pursuant to Section 2'10 >45 of f'the Penal IL >aw. .6 y SIGNATURES & OF1FICL41L TITLES. Mailing Address: ..................................... PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEAL_ TH SERVICES .. .,� r '•.. M' .r a r. :.K ft N-r•. �, -.. _. .... ✓.. � �c .a ..• •t - " • - • - - c ... � w .- w c ...- 1...�..c � • _ DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner �'% . � YY �'/ Address )99el it a17 i,6d t0 /9 s / y Located at'(Street)' r: - Tax Ma P - Block Z Lot �% l ndicat neares cross street) Municipality. / / a "n 4 e- Watershed SOIL PERCOLATION TEST DATA 1 Date of Pre - soaking Date of Percolation Test / 4 :�tf � I 5 3 �Z'y7 v 7✓ % %f /� 4 01 1 2 3 4 5_ NOTES:..:,, 1. Tests.to;be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted' for review. 2. Depth measurements to be made from top of hole. Form DD -97 TEST PIS' DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST }H[OL]ES. DP✓P'fH _....HOLP;1v0: _ .. MEENU. ....'HOLE IVO: G.L. %'off '�° % 0 /gym i� 0.5' . 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' Cd r71 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 10.0. d Indicate level at which groundwater is encountered Indicate level at which mottling is observed 40 11 Indicate level to which water level rises after being encountered S �e Deep hole observations made by: �� �j /�i �''�J Date s Design Professional" Address: o/� Signature:. Friction PLASTIC PIPE: FRICTION LOSS PER 100 FT. 3/8n 1/211 3/4 1 n 1 i/4 n 11/2 GPM GPH- R. lbs. Ft. Lbs. Ft. Lbs. Ft. Lbs. Ft. Lbs. Ft. Lbs. 1 60 4.25 1.85 1.38 .60 .356 .155 .11 .048 37.7- kvo 2 120 15.13 6.58 4.83 2.10. 1.21 .526 .38 .164 .10 .044 . 3 180 31.97 13.9 9.96 4.33 2.51 1.09 .77 .336 .21 .090 .10 .043 4 240 54.97 23.9 17.07 7.42 4.21 1.83 1.30 .565 .35 .150 .16 .071 5 300 84.41 36.7 25.76 11.2 6.33 2.75 1.92 .835 .51 .223 .24 .104 6 360 36.34 15.8 8.83 3.84 2.69 1.17 .71 .309 .33 .145 8 480 63.71 27.7 15.18 6.60 4.58 1.99 1.19 .518 .55 .241 10 600 97.52 42.4 25.98 11.27 6.88 2.99 1.78 .774 .83 .361 15 900 49.68 21.6 14.63 6.36 3.75 1.63 1.74 .755 20 1,200 86.94 37.8 25.07 10.9 6.39 2.78 2.94 1.28 25 1,500 1 38.41 16.7 •9.71 4.22 1 4.44 1.93 30 1,800 13.62 5.92 6.26 2.72 35 2,100 18.17 7.90 8.37 3.64 -40 2,400 :.... .... _....:...__.. :- 23..55 10.24. ~2,700 29.44 12.80 1 13.46 5.85 50 3,000 16.45 7.15 60 3,600 23.48 10.21 C/� ►�' �� ��'� ;�. � .� Cdr 37.7- kvo 1 PUTNAM -COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL° INDIVIDUAL /COMIVIERCTAL;SIT 'INSPECTION- OR1V1 SECTION A. GENERAX, INFORMATION Name of Project L "U ?Z'r _(T)(V) (;� County Site Locatiori- . 0f A7L6 Building construction :begun Extent . Is property within NYC Watershed ? ................. a Yes No av SECTION.B. TOPOGRAPHY (Please check all appropriate boxes) 1. 0 Hilly- --a Rolling Steep slope Gentle slope F7. Flat 2. Evidence. of wetlands / Low area subject to flooding Bodies of water . aDrainage ditches F-1 Rock Outcrops 3... Property lines or. corners. evident.... ...................: . No ..1........................... �e . �. . $ 4. Do water courses exist on'or adjoin the property ?............. .. ................ ; Z Yes F7 No .. v 5. Will these affect the. design of the sewage system facilities ?............ Yes No 6. Do watershed regulations apply in this development ? .. ....................... Yes No 7 Will extensive grading be necessary? ................: .:.....................:....:.. Yes No 8. Will extensive fill be necessary, for, SS TS? ..................... ....... Yos ' No' - -- 9. Do filled areas exist within the SSTS area ? .......... .......................... ; Yes . 'No If yes, what is the condition of the fill? SECTION C. SOIL OBSERVATIONS 10. Appearance of soil: Sand F_� Gravel Loam . 0 Clay ' a Hardpan F7 Mixture 11. Observed from: a Borings 0 - Bank cut ' /�Backhoe excavations . 12. Soil borings /excavations observed by 69zz; may) on 312 3 13.. Depth to groundwater 5Xe - dese_,P' H-1 on 14. Depth to mottling. �%sGi- �i��'`� J on 15. Are test holes representative of primary & reserve areas ...... ............................... Y.es a No 16. Soil percolation tests made by on 17. Soil percolation-tests witnessed by ��/ on SECTION D (on back) Form ST -1 2 SECTION D. bR- kINAGlE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Q Yes No 19. Will groundwater or surface drainage require special consideration? .......... ...........:. 17Yes N o 20. Will gullies, ditches, etc., be filled and watercourses be relocated?. ........................ Yes o 'SECTION E. REMARKS 21. If a common water supply is proposed; has an inspection been made of the existing or proposed source and facilities? ...... ...........: ............................................ :. Yes o Inspection data 22. Do adjacent wells- and/or sewage systems exist? ........................................... .......... YesNo 23. Additional comments '' 24. Site observerinspector.and title 25. Date( s ) -of pbservation(S)inspection(s) a 3 /0:, 'TEST PIT PROFILES Hole # Lot # Hole # 'Lot # ..Hole # Lot # Depth to water T. Depth to water A. Depth to water . _ . e BDe p thto mottln g_ [� © . e F tlto- znott�3n g �G^ not`ia g -- Depth to rock/imp. Depth to rock/imp. Depth to roc' Vimp. G.L. - 0' 73 G.L. G.L. 0.5 .0.5 A ... 0.5 1.0 df ovvo 1.0 . u"d - - 1.0 s 2.0 �j atinui y 2.0 Ui S _ 2.0 3.0' CU���f v��. 3.0� 3.0 4.0 o 4.0 4.0 5.0 5.0 • - 5.0 6.0 C 7.0 8.0 6.0 6.0 7.0 7.0 8.0 .8.0 9.0 9.0 9.0 10.0 10.0 10.0 SENDING CONFIRMATION DATE : MAY -29 -2003 THU 08:14 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 919149624248 *51 PAGES : 4/4 START TIME : MAY -29 08:11 ELAPSED TIME : 02'12" MODE ECM RESULTS OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... 0'6' 0.01 0'01 0,6 0's 0 8 016 oc 0;� oe p•y' 09 0[ p F 0.9 o's 0'4 0'E 0'S n�}7 0'b �0£' o.L .�m1d rnJ VE 0•Z i . O.T. i TO • S0. .. S'0 : dm 0ox 01 TpdaQ • "'tip Ca cq �Q I O. '��Ota of qu1aQ . — q,y —'. g�l7iom o1 .. �¢U:low of gidaQ g7daQ pmOwm --A of waQ —.�� • . O pl T&Q ia3eM g1diQ •L # 10 ... •�iaA+ of Q � • . 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Well fcCaI' O W Street ress: 11 T Tax Grid # Map74.1 Block / Lot(s)4_1 Well Owner: e: 1!2eQ 626�� Address: Use of Well: 1- primary 2- secondary dential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment 7Z1 Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing )(Detail§ Total length Length below grade Diameter Weight per foot Z4 ft. _LL". to " in. /(� lb/ft. Materials: � Steel Plastic _ Other Joints: _ Welded � Threaded _ Other Seal: _2�- Cement grout _ Bentonite Other Drive shoe: Yes _ No Liner _ Yes 5 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 Hou'r l Yield DO gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve anal3�ses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) ]Formation )(Description ft. ft. Land Surface a n PS, goo G " a If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capac'ty Depth 2:10 Voltage 2,1 m HP Tank Type A, ifo Volume - 7 Date Well Completed if r JIJ3 Putnam County Certification No. Date of Report ell Driller (signature) nuli r,: jrxact location or wen wttn aistances to at least two permanq�tt lar=Arks to be provided on a,separate sheet/plan. Well Driller's Name ; Address /r Signature: "'"' Date: _ White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY. DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT •Well L6cafiroiY • -'Street- - Map7.f,l Block Lots) 4- j Well Owner: e: Address: Use of Well: 1- primary 2- sec6ndary P dential Public Supply Air cond/heat 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 `7�Oven hole in bedrock Other Casing Details Total length Z .ft. Length below grade . Diameter to ` in. Weight per foot alb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: _X-- Cement grout _ Bentonite Other Drive shoe: -Yes _ No Liner:— Yes >-e, 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 /b gpm Depth Data Measure from land surface- static (specify ft) 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 167k n a ©o - ; 71 Rnn If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capac'ty 10 Depth Lel;-3 Voltage b HP - Tank Type. Volume C Date Well Completed. 1 f r j Putnam County Certification No. Date of Report 5 A ell Driller (signature) - 44� NOTE: /Exact location of well with distances to at least two permanefit landmarks to be provided on a,separate sheet/plan. ��%%� Well Driller's Name / Address/.r Y , Signature: '°" Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange.copy = Well driller Form WC -97 '.'''�� - .w c:... x r^ ".,p' .n . >- �. ..y,.G .:.Mr. 4 .rr: - .•.r ate. _, 1 • _ •V .. oB D, >P .Box :�� ,_ •, y, r :. i % ��� `.F V /�'.+' • w{/fY Brn Vif�M j�f1��f,,y Q.�'p' y /�fw/,ry.�'1 t� ll. �1 J. I > .. - ✓ri•� !'✓ /,`�[S:W.Ld'asPr `,^f.. ,..4 ,• . i `�� ,•�' .. � `' <'�f .. 1'JddT�' .�a'9.�':.C,`,� d',�' .�'�"!'eRS. c�;- e��,•r!Cr�� 7 Gd GI• d. oe12ra° JC 0%69 / ,yelp Ali o �l 4 ' I n Pe, AIX PUTNAM COUNTY DEPARTMENT, OF HEALTH i `© yt `. ' DIVISION OF E VIRONMENTA4 HEALTH SERVICES �� •� ` Ar F Is � /l �V13 -03 ; APPROVED'AS NOTED FOR CONFORMANCE WITH7� - SJrTrD;? 1 APPLICABLE RULES AND REGULATIONS OF THE - ` PUTNAM COUNTY HEALTH DEPARTMENT. ,y 24885 a' At- DATE . e die po ®al system. wasr an ar_d that the system Ls covered over. The' acesnatysisr titfnrsodium(1ki) i-, - -� i +. .. .. a.....a..+.A. Water cou4 Un a L(1_11 :. is •f?:��){, 6a U7,;,.iIra SEICUI£: not the med f Or 1 � ,,.gyp• � J't�'�` i � C 4Y f� � tk Vt l i L, { 11 L, 1 � ,,.gyp• � J't�'�` i � C 4Y f� � tk Vt l i { 11 L, 1 � ,,.gyp• � J't�'�` i � C 4Y f�