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