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Home My WebLink About4110DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.73 -1 -42 BOX 31 I rm 91 r I Is 1 , , , 04110 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT_ SYSTEM REPAIR YES NO Internal Use Only PERMIT #1e ❑ I� Repair Permit issued in last 5 years 0t in Watershed ❑❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated Repair within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joint Review SITE LOCATION -TOWN :2. TM #g ,3•�,3 I�o� OWNER'S NAME JI ,- n O ,?Al c 1 PHONE # PVJ =�� -9 MAILING ADDRESS �-2 G PC,4,5�l.J1 �r� C./4-dC�— F'�Q kS�� LL APPLICANT Name & Relationship (i.e., owner, tenant, contractor) /Me" DATE �'- rd�_ /a FACILITY TYPE ZV-0 Ie- ! 9rrQ, PCHD COMPLAINT # PROPOSED INSTALLER Oe c 10, 0;eA,vj S ,Z.,Ic< PHONE# Qty -) 9,0 / ADDRESS 3 Li 4e,)o,&Y1 /Z1) Coo -Tr-�&D'f REGISTRATION /LICENSE # Proposal (include a separa a sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. ^ , , _ ._1 I h I, as owner,agree the SIGNATUR (owner) / I, the sept' nstaller, i�9 ate n this form TITLE DATE to comply with the conditions of this permit for the septic system repair SIGNATl7RE . ,%�,�.� TITLE �R S DATE (installer) Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be bac ntil authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ Signature & Title Date / Ex (ration 6al iosal is in compliance with applicable codes Yes No O COPIES:- - PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 f Y/�Pb 1,4 � 1-1 a Cn, WLLL UUrLrLJ111U1V ruxuni DEPARTMENT OF HEALTH .Div4slbr;'Gf PUTNAM COUNTY DEPARTMENT OF HEALTH office Use Only WELL LOCATION 7T—REETAOURESS. WNW I TAX GRID NUMBER: 26 Pleasant Rd. Lake Peekskill,NY WELL OWNER NAME: ADDRESS: James OtBrien, 26 Pleasant Rd., Lk.Peekskill, NY 10537 10 PRIVATE 0 PUBLIC USE OF WELL I - primary 2 - secondary ID RESIDENTIAL ❑ PUBLIC SUPPLY 0 AIR/COND./HEAT PUMP 0 ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION 0 OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY 0 AMOUNT OF USE YIELD SOUGHT — gpm./NO. PEOPLE SERVED _/ EST. OF DAILY USAGE gal. REASON FOR DRILLING E]REPLACE EXISTING SUPPLY ❑TEST/OBSERVATION ❑ADDITIONAL SUPPLY ONEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 5251 ft. I STATIC WATER LEVEL ft. 1 DATE MEASURED 6/29/93 DRILLING EQUIPMENT :Q ROTARY a COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE 0 SCREENED ❑ OPEN END CASING E0 OPEN HOLE IN BEDROCK 0 OTHER CASING DETAILS TOTAL LENGTH _,3-1— fit. MATERIALS: 3 STEEL 0 PLASTIC ❑ OTHER LENGTH BELOW GRADE __2_0 tt. JOINTS: ❑ WELDED ID THREADED ❑ OTHER DIAMETER 6 in. SEAL: 99 CEMENT GROUT C3 BENTONITE ❑ OTHER WEIGHT PER FOOT 19 1b./ft. I DRIVE SHOE: WYES ONO_j LINER:OYES ONO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (it) DEPTH To SCREEN (it) DEVELOPED? FIRST 0 YES ONO SECOND: . ..... . GRAVEL PACK 1 0 YES ❑ NO GRAVEL SIZE: DIAMETER OF PACK — In. TOP DEPTH —ft. BOTTOM OEM — K. WELL YIELD TEST If detailed pumping METHOD: 0 PUMPED i tests were done is in- OCOMPRESSED AIR !ormation attached? ❑ BAILED ❑ OTHER 0 YES 0 NO WELL LOG it more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- ing Well Oi3- meter In FORMATION DESCRIPTION cooe WELL DEPTH It. DURATION hr. min. DRAWCOWN It. YIELD 9pm. SurlaLand ce 7 DrillLng--in overbilrden clay and bouldl Hit r,)ck at 7' 525 6 485 3 7 31 Dx:illLng in rock, set casing, grou;ed illLng in vock aganite. 1 9 WATER ❑ CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS 0 COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? 0 YES 0 NO STORAGE TANK: TYPE CAPACITY GAI(.. WELL DRILLER NAME p.F. Beal & Sons ,Inc Zj.oA k 6 / 9 / 9 AOoREss 4 Putnam Ave. SIGNATURE Brewster, NY 10509 PUMP INFORMATION TYPE CAPACITY MAKER DEPTH MODEL VOLTAGE — HP 1/69 rs DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914).278 -6130 y. APPLI CAT! 0t31CF— C6NSTRUCT'A GA4ki PCHD PERMTT 9 IiVii/ �' LS WELL LOCATION Street Ad es Town Village City Tax Grid Number WELL OWNER Name Mailin g .9��'" . 62016 7V �C Address rivate xe'66 S.epS' 6 SE OF WELL - primary 2 - secondary 6RESIDENTIAL OPUBLIC SUPPLY ❑AIR /COND /HEAT PUMP /QABANDONED 0 BUSINESS O FARM ❑ TEST /OBSERVATION O OTHER (specify ® INDUSTRIAL O INSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGEoZ -7D gal REASON FOR DRILLING REPLACE EXISTING SUPPLY O NEW SUPPLY NEW DWELLING ® TEST /OBSERVATION ADDITIONAL SUPPLY ® DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING '44--2k/ WELL TYPE 10 DRILLED ODRIVEN []DUG [)GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES 1,-'-'NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name& %fie ILJ_a�s ��C. Address : ��a✓�%�Z /U-� IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO � DAME OF PUBLIC WATER SUPPLY: A A-,407 fi'!� TOWN /VIL /CITY �Ai�i�•' ��j, DISTANCE --TO. PROPERTY FROM- NEAREST 'WATER-'MAINS - • _.:.. . LOCATION SKETCH & SOURCES OF:CONTAMINATION PROVIDED S/'o elf- 5 -) ®ON SEPARATE SHEET r Oat''). 77, ( nature) `- PERMIT TO CONSTRUCT A WATER WELL Thfi construct one water well as set forth above is granted under the provisions of`.Subp.art 5: -2 of Part 5 of the New York State Sanitary Code, and provided that within thfrti•'(30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or other contaminate surface or groundwater. Date of Issue• h 19 [.. Date of Expiration C. 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller -7 Y 7,r/e ::/ , 11: 7A, e.6 9 R Z EO 22 WC.Sr Irr, r77 /1 0 &,y r /Y* 0 Al, Sh a ON 7- 0.5 11Y 7W-4' TO W/`/ S K /Z 4 Ir./y 119 /V: CO, A,V 7TC 90 C 119 /le o4,0 0 9 7'10 I CO- - lgxSlv4,, C o m m o v A-V e P 4 r Z 9N0 7 A. �9,Yl 77R 71Y 1N9ecaep*,v" mil rw m6, m,A, 1 Vrvvo 9A 0.S Fo -& r,, ra a %fuu Vo M, V. J4 o-P -�4 r,? 9 IA)r8 -370 16r 80.00 0494" - SS-1 .7A 4 o r 2 2 -.B4,t. P_ - Joc Aol 1� z Q) %'Vol �1 Q1 o x/9,25- pose Cleo rc) 19AC SHOWN J% �c QE Irr Ad. �POeI4 2 S?"l R A 0i ki tli,D err. ovv A) v 33' .7A 4 o r 2 2 -.B4,t. P_ - Joc Aol 1� z Q) ,DOC- %'Vol �1 Q1 o ,DOC- 2_z: /'299-./7 %'Vol x/9,25- pose Cleo rc) 19AC SHOWN 2_z: /'299-./7