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HomeMy WebLinkAbout4412DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84.11 -1 -17 BOX 33 110 r r. 'Ap�� r . X km! T • ri is , I , ' �` I �. •,1 =_ L • 4 .j ' 1-i A. ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT 1V omS, _P.E. MPH Director of Environmental Health. March 20, 2014 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 . Phone # (845) 808 -1390 Fax # (845) 278 -7921 John Gafkowski 274 Peekskill Hollow Road Putnam Valley, NY 10579 Re: Addition — A- 033 -14 No Increase in Number of Bedrooms 274 Peekskill Hollow Road (T) Putnam Valley, T.M. 84.11 -1 -17 Dear Mr. Gafkowski: MARYELLEN ODELL County Executive This Department has received and reviewed the plans for the proposed addition to the above mentioned residence. The proposal for the addition has been approved 'as per'plans bearing the approval stamp from this Department dated March 20, 2014.. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this Department. 2.... The.area of the existing sewage disposal system and its.expansion:areamust be' maintained...... .. .. . _ ...... ... , . ,. _... ... _ .. .._..... 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc ... 4. The approval is for the modifications only and does not validate any construction shown as existing that has not obtained proper approvals from other agencies having jurisdiction. 5. This approval is valid for two (2) years and expires on March 20, 2016. Any permits or variances required under the jurisdiction of the Town of Putnam Valley are the responsibility of the applicant. If you have any questions, please contact me at (845) 808 -1390 ext. 43261. Respectfully, . Gene D. Reed Principal Engineering Aide GDR:cw cc:. BI (T) Putnam Valley :7l ii.,( ::f�V `it t �a7L 'l: _li it �.'f i_:} •:;I -�.s.. I i - lulA g S 1 t,, 5 dICA Ol'ik'•._'f _.0 _. .l 1 C' l lid ; - �f- - l 3 , Y ` s BEDROOM # F—P0—TE—N—flAA2Ls-7 BEDROOM I .0 nor #a DINING ROOM - CAVIL AREA 60' 0, 20' 112' 1 14' 4' 6' 0' C C @ IZZ 9W #2 I T z iJ 1 0 BEDROOM ROOM #2 POTENTIAL BEDROOM 3' V ElMap lil J4 ILASELS 7. LIVING ROOM BATH #1 204 R:) 1 0 % YOB. L PXWrRV - - - — I SO CATH. AREA 17* 0• 16• 4.Z/2- 11 • 11 1" 1. FILL 7 11 02 KITCHEN 9012 mm 7- HALL RAISE CLOSET FLOOD 24•— 2054 6' 0' C C @ IZZ 9W #2 I T z iJ 1 0 BEDROOM ROOM #2 POTENTIAL BEDROOM 3' V ElMap lil J4 ILASELS 7. LIVING ROOM BATH #1 204 R:) 1 0 YOB. s L 24' 1/2• I SO CATH. AREA 17* 0• 16• 4.Z/2- 11 • 11 1" 4 INXt 2-1 I�A'■ 1/4* OUCAO LAN n NuFt 2.-2* WF 02 3- 2 3V4' a ol Q 16 �65 1/2" ' 4. 1/2' a' 11 1/2, 6' 0' a' 0* 2.'- 2 1/2`• 5. 9 1/2' 4' 3 1/2" 3' a 1/2 8, 0, - 16, 0* X A-7 x 36 x 6 -$•n Y.3z 8 c) 1 xsg/l (v t=ip --.`.4 L BEDROOM BEDROOM #3 No Wmftt a- mm WF 02 i 45' a 1/.' --1 0. C 14' 2 1/2• (D 6' ol 8' ol 6' ol V. — ,, SERIAL NO-� 49344-' ALLEN BEALS, M.D., J. D. MARYELLEN ODELL Commissioner of Health County Executive. ROBERT MORRIS, P.E. 1. Director of Environmental Health DEPARTMENT OF HEALTH ' 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 ADDITION APPLICATION - RESIDENTIAL ONLY Owner's Name: �� 1� CA K , J �% 1 Owner's Phone #: /? Site Address:._�34 P,'Ak kl o 41W { Town: 1i V 0'.- V 'Tax Map # Owner's Mailing Address: 5 ahl (G f�_) A YV) J Owner's Signature: Description of Proposed Addition: ✓ 1,— *Number of existing bedrooms: Total number of bedrooms (existing + proposed): = * (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) * *Any addition which is considered a bedroom requires formal approval of plans (Construction permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the - , ... Putnam- Couny Sanitary Code:: Please - .. t .. submit this form and the following to Putnam County Department of Health, 1 Geneva Rd, Brewster, NY 10509, Phone: (845) 808 -1390. 1. Certified check or money order for $100.00. 2. Two sets of sketches of existing floor plan (drawn to scale, all living area including basement, to be shown and dimensioned and use of each room specified). (See Section 3.c of Bulletin HA -1) 3. Two sets of proposed floor plans (drawn to scale — with name, street and tax map #) * Non - professional sketches are acceptable and preferred. (See Section 3.d of Bulletin HA -1) 4. Copy of survey showing all well and septic locations on the subject property to the best of your knowledge. Contact this office with any questions. 5. Copy of Certificate of Occupancy from the Town or Certification from the Building Department with legal bedroom count of dwelling. OFFICE USE COMNMNTS r 5. Rev. July 2013 #31 Ar Ar .. . ... ..... t ...... �.. . _. .. .. - ... ... �.... .,� .... �. �. �.. ... - r r - . ... _... �. �. ... � .. �... �. ... ... -. .... ... V . � ... . � . f 4 ,t 1 � �' .r Town Legal Bedroom Count & Proposed Addition Status Re: �hn G A"6' (Owner's Name) Tax Map # 15 -1. 0 — / ° 17 Address: c27!4 a-e KS K! ow Town: C4 -0 n Vn YeLlIgAzi Year Built: According to records maintained by the Town, the above noted dwelling, is v in compliance with Town Code. Is not in compliance with Town Code. The Legal Bedroom Count is: This information. has'been obtained from: � - - - •- • - - - - 9 Certificate of Occupancy: Other: LAS��4�1C S HeRok jd`uv� The plans for the proposed addition are considered: Addition to existing house only Teardown and/or re -build allowed under Town Regulations T tkn, C�-, a �m -k -N- Building Inspector 1 3-M 14 Date Rev. Located 3 �8ti PUTNAM COUNTY IiEPYRTMENT OF HEALTH Division of Environmental Hesilth Services., Carmel, N.Y. 10512. Engineer Mu;vt Provide P.H.D. Permit # -—,C:f— EOE SEWAGE DISPOSAL SYS' Owner /applicant Name -Formerly Mulling Address � c'? .LJG, -/ zip / L r(i 2. Town or VWhge'��-� —'' Tax Map — Block_,__�,t! ___Lot ✓�_ Subdivision Name 4 r /? Subdv. Lot #_ Date Permit Issued - /37 / Separate Sewerage System buff t by / �u f'� 'd ! �� ' (�� =! c Address % �? �� r.�/� l �'! /V t . ; _ate' " Consisting of _. '� Gallon Septic Tank and .:> Water Supply: X Public Supply From Address or: Private Supply Drilled by "1' ' / � Yt S /1' Address ILI' Building Type `�2 Has Erosion Control Been Completed? Number of Bedrooms'-- Has Garbage Grinder Been Installed? All � Other Requirements .� I certify that the syetem(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and regulations, in accordancerwjth the filed plan, and the permit issued by the Putnam County DeI" rtmentfOf Health. , .a" Car, ifled.by� r Date Address -.:�1 f' � License No.';�' v -r S Any person occupying premises served by th�46ove system(s) shall promptly take such action as may be necessary to secure the correotlon of any unsanitary conditions resulting from such usage.. Approval of the separate sewerage system shall become null and void as soon as a pubt;: unitary lower 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 sublect to modification or change when, in the Judgment of the Comm siofw of fHealthh , ��uC%jhrevocation. modification or change Is necessary. Date "f7 BY� K/1!Pf� ! �✓ ' T it le' w u�r CZ7 rrc -r Y C-NNER Ay �v CR ==D r AREA lc=-.ted a:s Ec_ n — - Data cf- f i=- I :L7c- 2:1 C- 5 area- 11 cta E E Ind f- ------------- R SE-aGZ D7S-zCZ. . ..... ..... .... . cr: .C- C -U- L COT =.L7 ==7-= ,=-7E-*,'C-1 - WE A-- c r-''' ties cl, Y2=.- CN Ecl D.; ctancs L-O le C:l r-.=e CZ 20 C. 10 f= Se < 0 C� CZ!r ,roc C C7, Pig ea 1+ cr C17-E! c s Z I:e= C-,7c-, E�E Z:a C-: V- T�- - F 2.c c-7 :=�- E3 -anc= C- C: c az--a C- --'I r: -a' C- or- 4i 11 =r; C_ 4 `i i of h—� i=es flu,� :-A " Jai . . . . . . . . . . . . . . v X r- t E i. Z.- a < A" C 7 .-z instai-I-4 acz=r-4-- to V-1 -E-11 rrzte---' f. c=- n -_C:1 ar- 14% crctz* =-� c s cm siccas 1+ - DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914),225- 0310._, APPLICATION TO CONSTRUCT A WATER TELL PCHD PERM]CT 9 0 �4V ALL LOCATION Street Addre l pp Town/Village/City Tax Grid Number WELL OWNER Name ailing rf C ; -h Y -3. Address .9,1;,0-7 dlew Ore , a,5.5 in ,,]L5 rivate ® Public USE OF WELL 1 - primary 2 - secondary RESIDENTIAL BUSINESS ® INDUSTRIAL 0 PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP 0 FARM 0 TEST /OBSERVATION 0 INSTITUTIONAL 0 STAND -BY 0 ABANDONED 0 OTHER (specify AMOUNT OF USE YIELD SOUGHT �� gpm /# ® REPLACE EXISTING SUPPLY kNEW SUPPLY NEW DWELLING) PEOPLE SERVED � /EST. OF DAILY USAGE O(i a1 0 TEST /OBSERVATION 13 ADDITIONAL SUPPLY ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR 'DRILLING WELL TYPE DRILLED ®DRIVEN ®DUG 'GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF TELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF DIVISION: Lot No. STATER 14ELL CONTRACTOR: Name 1.1 • e• %? Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 1/' NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED 110" SEPARATE SHEET (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. 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 otherwise contaminate surface or groundwater. Date of Issue: 9 Date of Expiration 19 Permit Issuing Offici Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller `DESIGN DATA SHEEP- SUBSMCE' SEWAGE DISPOSAL SYSTIIrI .. ' ` FILE NO. Owner Address %'h� /� 6�r'C-P-zje Located at ( Street) � E'-��/7 ��/ ��1 Sec. . /% Block / Lot 17 (indicate nearest cross street) , Municipality Ay�. / �/ Watershed SOIL, PERcoLATIONaTEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking -'�C Date of Percolation Test HOLE 2 NUMBER CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 2 %1fiV ��� 4 5 4 Ly 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to'be suhdtted for review. 2. Depth measurements to be made from top of hole. 9/85 L TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION IN �Ji.. NT_ HQLE:_NO: G.L. 11 :.i 2 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDRATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: '`� DATE: -� A4 L>,4&?, DESIGN _ Soil Rate Used A) Min /1" Drop: S.D. Usable Area Provided '/ No. of Bedrooms -3 Septic Tank Capacity J 6) U CH gals. Type Absorption Area Provided By L.F. x 24" width trench Other Name C 1 / Gl f/ / 4`er Y Address? THIS SPACE FOR USE BY Soil Rate Approved �t. OF NFW R Signa S x ,y L -A 9 ONLY: sq.ft /gal. Checked by Date ,. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property of 964n Al ra Located at Date 9Z i✓;e N/ t- X-Aaj/ 1 (T), e " Section Block ' Lot Subdivision of Subdv. Lot # Filed Map # Date 1�t Gentlemen: This letter is to authorizes a duly licensed professional engineer or registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions, of Article 145 or 147, Education Law, the Public Health Law, and the.Putnam County Sani- tary Code. Countersigned: a , Address 4 W Mj ar' •! � � ,pF &OF elephone %� 7,/,), el— > Very truly yours, Signed e - 1�"� caner of Pro rt/y� Address �/ r� Town .Telephone C= E-,, CZ, 7%= c I:CN of C_ TS ice' 7 cri Z--, c2ze- ur--,C.,l Ea=- C11 rat C-a-= ac_= Lca <tan, c BC cecth 3—M9 cz 1=:-- I W, .7. c7au-c-as CE CaL:CES G �-- 71-S.- CM a�Z ca Zc- CNI _Z D c 5ziZe, cetal.-L CC--' c ta- --ur_ DrIVZiEV -Z C- anz 17�a 1 -P -t & D B c & cf 2 C7 N & (T:.ci ic 1/L Z;7 aN C.: 10, to Dnve--y-lay, 20' C- iqE' 100 , to Kajj; 200 in- loo, to, straam, Wat=-- inc. 131 t-2 Dra ric-cu t L 1:,- e E Consisting, of OOGi Gellot Septic Tank and d .. L Water Sapplyo Pabllc Supply From Address on Private Supply Drilled by Address handing TyPe Erosion, Control Been Completed?- .. 9. Number of Bedrooms Has .Garbag6 Grinder Been Installed? ` Other Requirements. ; I certify that�the system(s),as'lisl aervinq' the above premises were constructed essentially as shown on the plena of the completed work ( copies of '.which are attached)y,'and in`.accodance with the standards rules and regulations, in accordance` th the. filed plan, and the perinit issued by the Putnam County D�" r, bent f Health: Date.. .. C. if)ed y P. bE. R.A. a% 4 . �1 Addresf l�ll✓y0Y L q NO.� I 57c 5 _- Ices Any person occupying, piemims.mNed by -th bove'system( m s) shall promptly take such action as may be necetury to inure the correction, of any unYnitary conditions resulting from such usage.. A ro%41 of the separate sewerage system shall become null nd void ai soon as a pubt% sanitary ewer becomes available and ths' approval of -the private water supply shall' become'null,an when q' ".putilie vvete . supply becomes ilvallablR Such approvals are subject tTY;71 ti nor change, when, .in• tlie - judgMent,.of tlie`Com of Health, reyocstlon, modification or change is •neeespry, Date Title • A �� .. J7 .. J. it PUTNAM COUNTY DEPARTMENT OF HEALTH Rev:. 3 a8.6 % .. Divielon of Edihonmental°IEfeeltlt Services, Caimet, N Y 10512 Englneor Mast Provid ­P C H D Permit N 0 ✓% FQCATE OF CONSTRUCTION_ COMPLIANCE-FOW SEWAM DISPOSAL SYSTEM / - - — Lce8°/ .-: -- --- - - :w .. „.. "Town or Village � � //7 Tai Map / J BIoCIi =Lot' ,! Owner /applicant Name . °/” h �rta0 :Forme Sabdlvfelon Name w Sa Lot it MaWng Address /bdv `� n _tom Ci1'Y!l1SG ZIP % G�'S' �' Date•Permit' Issued /'Y9'Y�6�.1r - /o' /Gd��'i/// sa.t:�a `/ is _ � _ .•:.B� /may � 7 Consisting, of OOGi Gellot Septic Tank and d .. L Water Sapplyo Pabllc Supply From Address on Private Supply Drilled by Address handing TyPe Erosion, Control Been Completed?- .. 9. Number of Bedrooms Has .Garbag6 Grinder Been Installed? ` Other Requirements. ; I certify that�the system(s),as'lisl aervinq' the above premises were constructed essentially as shown on the plena of the completed work ( copies of '.which are attached)y,'and in`.accodance with the standards rules and regulations, in accordance` th the. filed plan, and the perinit issued by the Putnam County D�" r, bent f Health: Date.. .. C. if)ed y P. bE. R.A. a% 4 . �1 Addresf l�ll✓y0Y L q NO.� I 57c 5 _- Ices Any person occupying, piemims.mNed by -th bove'system( m s) shall promptly take such action as may be necetury to inure the correction, of any unYnitary conditions resulting from such usage.. A ro%41 of the separate sewerage system shall become null nd void ai soon as a pubt% sanitary ewer becomes available and ths' approval of -the private water supply shall' become'null,an when q' ".putilie vvete . supply becomes ilvallablR Such approvals are subject tTY;71 ti nor change, when, .in• tlie - judgMent,.of tlie`Com of Health, reyocstlon, modification or change is •neeespry, Date Title • A YML . ._...321 Kear.,' ELAP #10323 Environmental LAB NUM13EgZ 32.001621' Services DATE /TIME TAKEN 1 3/13/92 12:45 p.m. itreet, Yorktown Het -&s, NY 10598 DA�I� /TIM-E R -'D 3/_I3/9.2.: � ] :,15 ,p.�u;: : (914) 245-2800 - DATE REPORTED MAR, 17 1992 COLD BY I John E. Gafkowski NOTES X ANALYTE. RESULT UNITS Potable _ HNO3 _ ALKALINITY mg/L _ NaOH _ pH GT 9 X AMMONIA mg/L Na2SO3 _ >20C CALCIUM _ H2SO4 mg/L SODIUM • CHLORIDE MF MPN n-g/L SULFATE COLOR Units SULFIDE CONDUCTIVITY umhos /cm SULFITE COPPER mg/L TURBIDITY CORROSIVITY LSI ZINC " DETERGENTS FLUORIDE nig/L HARDNESS n-g/L IRON n-g/L LEAD mg/L SPC MANGANESE mg/L TOTAL COLIFORM MERCURY per '100 mL mg/L FECAL COLIFORM NITRATE per 100 mL n-g/L E. COLI NITRITE per 100 mL mg/L FECAL STREP. ODOR per 100 mL TON SAMPLING Kitchen Tap SITE RESULTS�•' TER TEST X ,I ANALYTE RESULT UNITS For Lab Use Only IpH Potable _ HNO3 _ pH LT 2 —<4C _ Nonpotable _ NaOH _ pH GT 9 X <20 >4C HCl _ Na2SO3 _ >20C _ STAT! _ H2SO4 ZnOAc SODIUM • ; MF MPN P/A SULFATE RESULTS�•' TER TEST X ,I ANALYTE RESULT UNITS P IpH S.U. PHOSPHOROUS n-g/L SILVER mg/L SODIUM n-g/L SULFATE mg/L SULFIDE rng/L SULFITE mg/L TURBIDITY NTU ZINC 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 sampl [WAS] [WAS NOT] [NA] of a satisfactory sanitary quality according to the New York State Sanitary Code, for the aram ers tested, at the time of sample collection. rt. These results indicate that t water ple [WAS] [WAS NOT] [NA] a satisfactory chemical quality according to the New York State Sanit y Code, o the parameters tested, at t e ti of sample collection. ' NA = Not Applicable N = Not Present (Negative) SUBMITTED BY: P = Present (Positive) SA = See Attachment(s) • = 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 COUN'T'Y DEPARTMENT OF HEALTH V.Z.SIOU.E)F.:.F1M- RQNM L L FaTT- 9- SE�ilICF cL..- - Owner or Purchaser of. Building J/ Building Constructed by Location - Street 14 �Ievll Municipality Building Type Section Block Lot Subdivision Name �-- 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 Cyyaaiszizcticn : Coi .:systn . 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 the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Director of the Division of Environinental 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 building utilizing the system.' Dated this / day of,'&;Z 19 Signature n . Title G'Neral Contractor ( er) - -Signature Corporation Name (if Corp.) rev. 9/85 mk ti Corporation Name (if Corp.) ct Address WELL L;1J1V1rLt_11UN mrxuru Office Use Only DEPARTMENT OF HEALTH of Hbalth Services PUTNAM COUNTY DEPARTMENT OF HEALTH STREET ADDRESS: TAX GRID 3ER. WELL LOCATION 77 -/ -1-/ L's il WELL OWNER -1 NAME: ADDRESS: 0 W S k /Zolko Ali x &PBIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary Q-9ESIDENfiAL 0 PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP ❑ ABANDONED 0 BUSINESS ❑ FARM ❑ TEST/OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑. INSTITUTIONAL 0 STAND-BY ❑ AMOUNT OF USE YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal. REASON FOR DRILLING .[]REPLACE EXISTING SUPPLY EITEST/OBSERVATION []ADDITIONAL SUPPLY ANEW SUPPLY (NEW DWELLING) [:]DEEPEN EXISTING WELL DEPTH DATA 300 WELL DEPTH ft. STATIC WATER LEVEL�_6 ft. 1 DATE MEASURED DRILLING EQUIPMENT atOTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG 0 WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING GYOPENI HOLE IN BEDROCK 0 OTHER CASING DETAILS TOTAL LENGTH 0 ft. MATERIALS: STEEL ❑ PLASTIC 0 OTHER LENGTH BELOW GRADE ft. JOINTS: ❑ WELDED - B-TkEADED 0 OTHER DIAMETER. in. SEAL:0 CEMENT GROUT ❑ BENTONITE Q&HER WEIGHT PER FOOT Ib./ft. I DRIVE SHOE. ❑ YES I� LINER: 0-YES 940- SCREEN ­_RETA_1LL._ DIAMETER (in) 'SLOT SIZE LENGTH (it) DEPTH TO SCREEN (ft) DEVELOPED? FIRST `0 YES '0 N HOURS GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE: DIAMETER OF PACK — in. TOP DEPTH —ft- Bum DEPTH — 11. WELL YIELD , TEST If detailed pumping ME-f�00: ❑ PUMPED i tests were done is in- (R,tOMPRESSED AIR : formation attached? ❑ BAILED ❑ OTHER '0 YES ❑ NO detailed formation descriptions or sieve analyses VELL LOG 'a'remov"ailable, please attach. DEPTH FROM SURFACE Water Bear- Welt Oia- meter meter FORMATION DESCRIPTION cam It WELL DEPTH it. DURATION hr. min. DRAWOOWN ft. YIELD gpm- Land Sur face r,/ .40 �l k� 7 I _3 300 WATER 0 CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? 0 YES ❑ NO STORAGE TANK: TYPE. (f I -T CAPACITY GAL.— PUMP INFORMATION TYPE CAPACITY MAKE DEPTH 28-6 k MODEL VOLTAGE. HP of WELL DRILLER NAME DATE ADDRESS IV-" "" " 4 d c- /-,V, SIGMMRE 0 K V, 11 , 4/1 3/69 __4