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Home My WebLink About4145DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.74 -2 -11 BOX 32 ror ,; - IN I Is I I III I y. me I �T, �' ' I6 L .1 T ■ � r � .' ' . 'L *r I ' 04145 Xvi 'T� ' PUTNAM COUNTY DEPARTMENT OF HEALTH /DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORTO -' P.,, Well Location Street A dress: Q, T N la je: e Tax Grid # . , Ma Mock 2 Lo s Cl M t(s) Well Owner: Name: Address-V�% 19'� - f � � ,��ZCP� �� - %�2.�2 %c7•- �G2'.e!zc. -C �l Use of Well: 1- primary 2- secondary c Residential Business Industrial Public Supply Air cond/heat pump Irrigatio Farm Test/monitoring Other(specify) 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 I Total length c904 ft Length below grade /9 k, ft. Diameter A " in. Weight per foot lb /ft. Materials: Steel Plastic _ Other Joints: _ Welded ><--Threaded _ Other Seal: g Cement rout _ Bentonite Drive shoe: Yes No _Other Liner Yes _ 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 Yield2 gpm Depth Data Measure from land surface - static (specify ft) 30` During yield test(ft) Depth of completed well in feet C0 Well Log If more detailed information descriptions or sieve analyses Ate available.. please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface y6' It .� If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type ,o� Capacity Depth • S`610 Mode ry �rjU Voltage Z,3o ' HP i Tank Type Volume �4V- 7 Date Well Completed Putnam County Certification No. Date of Report / / u Wel Driller (signature) e' 5,4� ,,y INM I Z; r ZXULA iucauun vi wets wttn utstances to at Least two permanent lanamarxs to ne provtaea on a separate stteeuplan. yWell Driller's Name Address: / r 7 , Signature: /% /,' �i , , Date: White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTIVAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ® APPLICATION TO CONSTRUCT A WATER WELL ® _ - lease x.r.�.ar.�•`- �- r--�- i ��' "'�PC;HD PCrTilit 4. IIVr V7 � t'/ ell L ati . S eet Ad ss: Tax Grid # Mapg&li Block Lot(s) Well Owner: N e Ad lay'7 Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation I- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage _gala Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) _,--`D-eepen Existing Well Detailed Reason ha , for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Lot -lo. Water Well Contractor: Address: Is Public Water Supply available to 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 sheet/plan. Date �- ® Applicant Signature:��%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. 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. Aj y revision or alteration of the approved plan requires a new permit. Well to be constructed by a water ell 'ller ce ified by Putnam County. Date of Issue �d 7 / Permit Issuinl Official: Date of Expiratiojl '_T/2 ® of - Title: Permit is Non- Transfirrdble V White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 «% ------------- - - - - -- ------------- - - - - -- -------------------------- 8 31 1 30 8818 ! 156 -- _ --- -- ! 111.42 7 32 38 ; ?9 a f67 27 0 ----------------- '� - -------- r--- - - - - -_ ------------------------ __- - 31 6 1°z' 8 33 ..- _ ! �'- - 7 28 .. - ----------- - - - - -- - - - - - - - - - - - - - - - - - - - ! 6 34 ; 27 rb9 - 0398 9318 ; 109.95 109.96 4 36 p 2B 160 8 -- — — — - -- ' -- - - - - -- - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - ------ - - - - -- - - --- - - - - -- o o 32 9 37 ; - sa 16r 2s 8 108.97 37 2 14 162 ----- ----- - - -- — 1 23 16.7 P 11367 103.45 ! 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A R � ! g 13 0c� 174 � o + A 12 0 EXEMPT,10 3' ! ------------ ------- - - - - -- --------------- ---- - - - - -- LAKE PEEKSKILL 104.09 » 176 IMPROVEMENT DISTRICT ! v -------- - - - - -- --- - - - - -- SINGER BEACH ! c to A fe ! 14 1018 ! ---------------- - - - - -9 - ! ■ 177 0 91.81 f0a53 21 -----------e------------ MOB ! a 178 - - --- -- --- - - -- - -- ; - --- --- -- - -- 10324 1b0A ' ! $- 15 g g 179 20 ------------------ - - - - -- ! ----- - - - - -- ------------------------------------ 6 too -------------------- - - --$1 ! 1o298 ------------------------- r�1 . 2 5 � 181 $ _1 1024 g 18 ° !62 -------------- - - - - -- i 4 ----------- ----- - - - - -- ! 2 18 g 10288 Free@nce F-1 Town Lines Parcels Old Parcel Lines IV Streams 0 Lakes and Ponds Wetlands Carmel Road Names . Ip Ken t Road Names [ Patterson Road Names Philipstown Road' Names Putnam Valley Road 1--L I I Names —11. Southeast Road Names I l I I Disclaimer: Page I of I FRINTOPT.TITLE.- MORRISSF-Y OR T'I http://imsserver.putnaincountyny.comIFreeancelClientILandRecordslprintFrame.htrnl 7/21/2004 0 DEPARTMENT OF E[ o�rAL HEALTH SERVICES 225- 3838/225- 3833/225 -3641 PROPOSAL: FOR .SGE.DISPMAL, SYSTk7t_REPAI OWNER'S NAME j L it d I"-V) �- /� a.c8 t.� PHONE 3,9 "�-- SITE LOCATION MAILING'ADDRESS name & xelationsnip (i.eo owner,tenant, etc.) DATE �/ TYPE FACILITY �ie ►W7� �`�o rn. PROPOSED INSTALLER tt -(JuJ ! /C lj 9 PHONE 32,6 Proposal.(include sketch locating all adjacent wells): NOTE: Repair must be in same location and of.sam,.type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. C. Proppopsal approved�y _ . Proposal Disapproved 1 v %lam :. a n . f 1 Inspector s Signature & Title { p Proposal approved with the .following �COV tions: 1. Procurement of any Town permit, if licabl 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to.two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam: x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to'be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE W 'd& '1 TITLE DATE 1. C.: Rdte (PCfD): YeUcw' (T„n HE); Pink (Applicant) SA ... . ...... Lk. 7X 13 0 -7: - /0 1 it - � 3' cil. #4 F 6 it 0 Wr*Lf- o fto r "core 13 Er f .t f .t SITE PHONE g2- 3 f IL TO its- -1- 0 MAILING ADDRESS S ds- PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i..e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED iNsTALLER 6-o-y Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require suhnittal of proposal from licensed professional engineer or registered architect. 0-, 30 r Proposal approved Inspector's Signature & Primal approved with the Proposal Disapproved conditions: a- - 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate shaving: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIG '`— TITLE _�. �iTE %® �°� CP PM: White (MV; Ye]1aw 03m EU s Pink (AnZoxit.)