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HomeMy WebLinkAbout0179DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 4.10-1-19 BOX 3 ;R��*TFti �,' , ' , I a F�a',�yq � F iXt�e/ Rt1 i� ■�Q l till �,��'rt x F s e k Pj �j "• �� ¢1 . �I g3 A q � � ` , 1 00179 t 110;OId Ri 6Ctr Phone 91:4. Carmel; New York 1051'2 1 YEALI PCJTYVAYYY OU 'Received _ .... 1D: ash G; 110 Old Rt 6 Ct[ Phone 914 225 0310 �armei= New York 10512 ate " 19 '� Hof u a�3 f i Check '- ❑ 11� 0 - fay 110;OId Ri 6Ctr Phone 91:4. Carmel; New York 1051'2 YEALI PCJTYVAYYY A�' ' Q .41 w Y WELL GUMYLh*1iUN icl;YUtct DEPARTMENT OF HEALTH Division Of Environmental,.Health Services PUTNAM COUNTY . DEPARTMENT OF HEALTH Office Use Only WELL.LOCATION STREET AOURESS: WN /vll ! l Y TAX GRID NUMBER: Quaker Hill Road Patterson WELL OWNER NAME: ADDRESS: 126.03. Thomas-J. Daly Const. Corp., 312 T tu.%ville..Rd. , Poughkeeps %e,' NY ❑ PRIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary ® RESIDENTIAL - ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS - ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED / EST_ OF DAILY USAGE gal. REASON FOR DRILLING ® NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 143 ft. STATIC WATER LEVEL ft. DATE MEASURED 1Q17/f3s DRILLING EQUIPMENT ' ❑ ROTARY a COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT, ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. © OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH 130 ft- MATERIALS: 0 STEEL ❑ PLASTIC ❑ OTHER LENGTH.BELOW GRADE 129 ft, JOINTS: ❑ WELDED C3THREADED ❑ OTHER DIAMETER 6 in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE ® OTHER WEIGHT PER FOOT 17 Ib. /ft. DRIVE SHOE O YES I@ NO LINER: O YES ®NO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (it) DEVELOPED? FIRST O YES 'ONO HOURS SECOND GRAVEL PACK O YES ® NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST It detailed pumping METHOD: O PUMPED ; tests were done is in- M COMPRESSED AIR , formation attached? O BAILED ❑ YES ❑ NO ❑ OTHER It more detailed formation descriptions or sieve analyses ALL LOG are available, please attach. DEPTH FROM SURFACE water Bear- in Weft Dia- meter FORMATION DESCRIPTION CODE,. WELL DEPTH ft, DURATION hr. min. DRAWOOWN ft. YIELD 9Fm Land surface 90 Overburden 90 143. x 6 Sandstone 143 20 ,WATER O CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? O YES ONO ANALYSIS ATTACHED? O YES O No STORAGE TANK: TYPE Diaphragm Pressure CAPACITY 40 gal, GAL. PUMP INFORMATION TYPE ,9Lbmersible CAPACITY] GPM MAKER DEPTH 110 , MODEL VOLTAGEZ� HP WELLORILLERNAME J. T. Eckerson, Inc. DATE 10/11 /RR ADDRESS Route 9W . SIGr`rATtTRE Milton, NY 12547 Patricia E. Freligh PUTNAM CMMTY DEPARTMENT OF HEALTH DIVISION OF ENVLRONIMMAL HEALTH SERVICES Owner or Ekirchaser of Building Ju0k� Osrfio Building C6nstructed by SAN- &A-Y- Og- Mkt U-1 Location - Street Municipality , Building Type 2 515- Block Lot Ai.i1_ L . '14 - S 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 constricted 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 disposal 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 the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Director of the Division of Environmental 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 199 rSignature Title GeMxal Contractor (Owner) - Signature Corporation Name (if Corp.) �S I� ! Address rev. 9/85 a S-33 mk Corporation Name (if Corp.) Address Yorktown Medical Laboratory, Inc. 321 Kear Street Yorktown Heights, N. Y. 10598 (914) 245 -2800 Director: Albert H. Pado van i A T. (ASCP) f -1 Michael Marsico 273 North State Rd Briarcliff Manor, NY 10501 L J REPORT ON THE QUALITY OF WATER LAB # - - - -- — Date Taken:. 1 -27-91 Time: 9 :10AM Date Reld: -91— Time: Date Reported:-' 9- yi Collected By: N. F+af s co . PO /Client # Referred By: Sampling Site: Kitchen tap: South Quaker Hill Rd. Patterson. NY Phone ( ) 9 �3 -3685 INORGANICS (mg /L) MICROBIOLOGICAL Alkalinity Chloride Copper Detergents, MBAS Hardness, Calcium Hardness, Total _ Iron _ Lead Manganese Mercury _ Nitrogen, Ammonia _.Nitrogen, Nitrate- -_ Nitrogen, Nitrite' Phosphate, Total Silver Sodium Sulfate Sulfide Sulfite Zinc, PHYSICAL MISCELLANEOUS PH (S.U.) _ Color (Units) _ Conductance (uhms /c) Odor (TON) Turbidity (NTU) a- _ Standard Plate Count (CFU /1.0 mL) Coliform & Related Organisms Circle Method: M MPN P/A Total Coliform Fecal Coliform Fecal Streptococcus E. Coli KEY FOR TERMINOLOGY IT = < = Less Than GT = > = Greater Than NA = Not Applicable SA = -See Attachment(s) TNTC = Too Numerous.To Count P = Present (Positive) N = Not Present (Negative) = Also done because To- tal Coliform Positive REMARKS COMMENTS Lab Use (For Lab Use) SAMPLE TYPE: ( Check One ) Potable Non- potable OUTGOING: (Check Each) HNO H013 — H2SO4 _ NkH ZnOAc _ Na2S203 _ Other: INCOMING: (Check Each) LE 40C GT 4 /LE 200C GT 200C LE 2 , _,pH pH GE 12 _ Other: NYS ELAP #10323 'THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WAS NOT) (NA) OF A SATISFACTORY. SANITARY QUALITY ACCORDING TO YORK STATE PUBLIC DRINKING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION. `THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DID NOT) (NA) MEET THE :SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STATE DRINK- 'ING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION. irector 7 /87(Rvsd1 /90)RWE WINVOICE WATER WELL DRILLING Rte. 9W Milton, New York 12547 (914) 795.2250 (914) 795.2518 Thomas J. Daly Construction Corporation 312 Titusville Road Poughkeepsie, NY 12603 INVOICE fig® 8065 October 11, 1988 Invoice Date L J Log of Well: 10 /6 /e8 130' Well started — _ —_— Feet of casing used Well completed 10 /7/88 Depth of well 143 a. P. M. 20 Remarks: yet pump at 120' Drilled by Ron,Jr. /John Nell feet from house Nell site Lot #5 - Quaker North Subd., Patterson (Putnam County) Description Price Amount Drilling - 143 ft. @ $8.00 /ft. -� $1,144.00 Casing - 130 ft. @ $9,00 /ft, 1,170.00 -6 c6 Interest will be charged after 30 days from date of Invoice at 2% per month - 24% per annum. Information on Pump: $2,314.00 FIIFL Si'I'F Pl lSPTQ1V Data Ins ^_t i bv- OR S[7DIVISIc3N LGT ff DISPOSAL APZZ� YES NQ CCi�' -"tT� a_ EDS area loct= as per approved laps Ia I b. F" l 1 section - Data of plac°np-nt r . 2:1 bari iex . LCTH W-= AVG . DPIH c: %tural soil nct s triune i i d_ Stone, brush, etc-, ereat_ r than L5' fran SDS area_ m e_ 100 ft. frcn wate—r Course /wetland-_ - Ii_ 5r: DISPOSAL STS= 1 a. Septic tank size = 1,000 1,250 b. Sceptic tank ir, to 1 le gel C. 10' miniir�m-n f_an fcurE tion I _ a- rC 90 b�n� r ClE = ^_CLit W? trlin 10 -f z. of 45' bend I �r e. DIS=--L'rICv ECX 1 All 1 cut1;T=: at *ne e? e-v tlicn - wat_r szea t ( I 2. P_ ct b�l^nT fres t ICI' I 2 f= criair`1 scil between box and t?". ='!ChEs f . j L-N=lIC -N ECX cr cce_,=i v se-" - . 7 Disaunc_ tc Wat-_ Ccu`.0 rEa.. -s r f-`. I I 3. Ins:-,=1 1 E ac rrC=I:G to plan I ta 4. Dis `.nce Ca?: ter tc canter i I i S-I cre cf t==,ce-! acc_ptle 1 /l0' - 1/32 " /fcct_ iw E. 10 f =t f =1 crc=e_ -line - 20 feet - fcurEaticns I. De=th cL ch < 30 LnchLcs frau SLr--aca E. Rc= a-' c-de:± fcr e- r...ans i cn, 50 9. Size of cry =ref 3/4 - lill Ire 10. Dent'1 of crave? in t=ench 12" mi n;rmrn I ( h. P T OR LX;.E SYST= s I Size of v I I 2. e e—fic q 4 . P.= ea -=ilv acc_sible manacle to grade 5. First bcax baff_I 6=1; I i G. Cvc-le w,t=e5 == by Health i Depa- t ent I � es-ti*n- ted P�-=- C.,7c? e - V. HOU _- a. E cassia lo—ted rE-ar a-morcve3 Tans _ b. cf berrocnL- V. WML z:-- per planss _ b_ D_tance farm EDS ar— me=cum f C. C zi.na 18" ahc� crrade- d- S,_ =ac= draim-c` arcur_d well accaptahle_ a_ E---Yes prccerly crcut b_ A_ pirzs �r=�i�ly baciLea (. �' c- P_ paces f! u<^. with. inside of bax I d_ ��C -11.1 mat_r . z l ccnta_, ns stones < 4" in & ameter ,� I �� e- C- -a i n drain it -st 1 1 e_d acCCrdina to elan f- C_ • a , n drain cut=all prcta=ted & dir. to evist_wat_rccurs� g- F=t- na drair_s d_zc-zarae aWav from SIDS are--- h- S=_ace wa.t_r Qreta t? cn aaeoua.te I fit_ i- �_csicn Ccnt.cl orcv4c� cn slotes ar =a.te_r tiLn 1.5 I I q kkr od, fl. ik ! above "d ®scnbetl will be constructs County arjr�6jrjt bo -submittid-;to :'thW'1Department villfbe 10,cated,as Oidwii iin the api 4nty'.0 t !p, D ate; Ad APPROVED F 3. CONSTRUCTIC revocabi f .r"u r1i 5fp5pv aF�l 2�� 1);that tnef'separatesewage d�iposalasyitem ,- stantlards rulesan 5 a t ions 0 J�'6;A h 9 1 that rears immediately follov/ileg the date of th® iitu JU nr"40 Putnam ... ........ A Nth Any change or alteration oC;construction gnly'. Tdto DT"S& 41, 'T 7.17 -7 it aF�l 2�� 1);that tnef'separatesewage d�iposalasyitem ,- stantlards rulesan 5 a t ions 0 J�'6;A h 9 1 that rears immediately follov/ileg the date of th® iitu JU nr"40 Putnam ... ........ A Nth Any change or alteration oC;construction gnly'. Tdto PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property o Located at Date F/S%�­dc (T) _Pioft%YN_'�' v T'j See -t+o . Block Lot 5 �� Subdivision of L� j, KC? Yti ��?r�j.' "�L Wofoer' 16el�' QetJ ft Lk " Subdv. Lot .# Filed Map # I5 Date . AUCHAEL DALY, P.2, Gentlemen: CONSULTING ENGINEER This letter is to authorize P- 0. BOX 243 , W. JM 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. Very truly yours, S' ned � Countersi e � Owner of roper y gr��` P.E. , R.A> , ## Address Address CONSULTING ENGINEER wn P. O. BOX 243 1 C-/./�/ 2v2 0 d `� Telephone Telephone h e PUrNAM COURrY DEPARTMM OF HEALTH ...,DIVISION OF'ENVIRONMENTAL HEALTH SERVIUS: DESIGN DATA SHEET-SUBSUFACE S&qAGE- DISPOSAL SYSTEM - FILE W. 7 Owner :::SoA A 63jk�OA —11,,i Address VA01-7, Located at (Street) See-. Ca Block Lot (indicate nearest cross street) Municipality j� Watershed M r 6KL%&A 2 C—tl SOIL PERCOLATION TEST DATA REQLT= TO BE SUBMITTED WITH APPLICATIONS Date of Pre-Soaking A%& - -L 220 Date of Percolation Test 'A 5,8 HOLE NUMBER C= TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Mter Level. No. Time — Ground Surface In Inches Soil Rate Start-Stop Min. Start stop 'Drop In Min/In Drop Inches Inches Inches 1 2 c.) 0 30 3 .3 1 3 0— it 4 17- 5- "Wom 2 1, 3 4 () — 3O 6) 5 4 ---' I- 1 21 � 13 If` A 2 3 NOTES: 1.`.-Tests to be repeated at same depth until approximately equal soil rates are obtained 'at each percolation test hole'o ; All data to' be sulmitti2d . for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENOOUN'rERED IN TEST HOLES DEPTH HOLE NO. 1 HOLE NO.. HOLE NO. G.L. 2' �� i►' 31 ` ►' 4' + I Y f 5 6' 1 8' 9' 10' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENOOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used 'L('% Min /1" Drop: S.D. Usable Area Provided��� No. of Bedrooms Septic Tank Capacity jam) gals. Type�� Absorption Area Provided By L.F. x 24" width trench Other ►cN o Name ' (' a I Y c,��,'� �l L7'Signature Addressc�x 7-47 3 SEAL �a� mR 46A THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date ot r r rg : id 49 o w ?ate 10 9 1 f �1TGN2A1. II r E a �1 0 / 777 _.P1oa�c ��� �/9, rn e L3 ;I�s A Zjm. Y-3o ?Il90 c D — ®� - - - yea � I���� `� ®, y2• ! emu-_ � to 10 . b CLLO. dqYF' 3 w PUTNAM COUNT? QpPR 'l F:7 ALTio � 7 PLANS .'APTIF - 0: ssl- W +.3 T :, � U' i`! 1 G T t fo mttovwo s6 d Q r - cn P-1 U cd w.g.� a ♦a a , ! 0 peN p• In a. :4 vve W_ • l.G.eq.- 6LQCO�3@iCaO&1 �.wt3�.fdE:.tt.6oa•:e., -_� "S�.00Sa�l�rare.(� ®�:�;•, . / A� ETA LL — •8 S7 a1tSP � VISI<o MOO. W" �8s��.= ►'o�o�uo�. � •9 � � i- (Zo a�'7" �> can e�ooa� o� Sao wo¢. wab EXCEL HOMES= r iu o s t o e_r E Pacmaw -- Og,Oca ®vas r`ogg _ P.O. • Son Gs OAAWN 01, jN r - 717 3 6 - 8971 MifflIntocn, PA 17053 o v c�nN4: - ' = p• EXCEL HOMES= DAAWN QY- P. o. -,sox -69 /�� i l /� � 9 A_PDE`iDIX B PT.Pl' -M (ML�Ft"J DEPART AF-W OF EFA=11 - DISTISIGN OF ENV=CI�.F -AL EEALm3 SZRXTIC:ES =N 1TICUPL W-AT --"7R SUPPLY & SUESURFAa Sr:r-A= DISPCEAL SIST-EmS' (Na,P of 0"ner ) RE-7=9 S'aC T - CCNST=ICN PERMIT DATE (- =c Lcc ticn DC 711E TS Permit Acrl i cati C.^. Ccrmr te- Resoiuticn Plans - Three sets Ehc? 2r--- s A-u '-ior_zet_cn D°_sian Data SL.e✓- (ACS) Dr=y Role L C CcnciSte_nt Perc Perc Hole Dec�"I Ecuse Plans - T.so set=- C�1ERPL Lac-al Sub v i c j cr-I ~�i- resign P -rcrcval jYe-' a d (Tc-- w- /D-EC. P--= -it = R L D) Eat. Cn DCS Plans & Psnz:i = . �. S=.vcC` SV= . e t i i 1 FrOL_l_ & D or J --1; ;qe i l `r j i , S `ri i cz Line i-' chi C nstructicn Notes (grinder rate) LIesicn TMta: per` and deep res _s T'wc -Foot C-- ntCurs Existing & Prores=-"� Drive:+7av & S1o_ces Cut Fcctir, G-0 er,Qurtain Drai nc (-;:sc Iar re OK P&--c & Deep F?cles E, -ca-ted Represantative Of pr-- 'rra.TV ard ex"...arsicr. Exp. nsicn Area; s_:C1vi7; - avitV flC d, C-af -. sip I_ Fst- P -t & D Box Shawn & D-e_ .ilw Douse - No. of BedrecAs ivells & SSDS's w/-in 200 ft. cf r occsed S_�s PrCCX" �y Mei—s & Eocum ;q Hcnse Se` k Necessary (Tic;.t 1ct) House S F-we'_ d "O; -TjTe Oi-..c No F32^ Max. Bends 450 wjcl= .out SF?Da.RP.TICN DIST=\= SPEC!= CN P=N Fields 10' to P.L., Drivewar, L�T-e T- e- zs,Tcg cf 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pit 100' to Strea-ma, Watercour-se, Lam. {8 (inc. e: 15' to Drains O: r-1-- i I, Leader, Foot-inc 35'tc catch L-asin,StOrLT=ain,Dlr:ei waEa—=: 10' to Water Line (pits -20') nitt ^t Cr? i n-a e CvLir —se 50' lnt� S`oLc T.nks 10' fran Found: ticn; 50' to 15' we-1-1 to PL ° SutDI T'SIC rz- � rZ-f' F - _ --- to crrtc -u s 1'00 I ✓� � I I ✓i^ _ I - I I L—F F T=-I, S SST` •TC I � --�`�� I clavcp—?-r- _r 10 ft. filI notes U&4ZIO L--j- -- n�.,; deyth c =,uc =s I ✓J 100 vr. flccd ele1T. 200 ft. res=qoi =, etc. 150 ft. trig; ll /cal? . Ecuse Plans - T.so set=- C�1ERPL Lac-al Sub v i c j cr-I ~�i- resign P -rcrcval jYe-' a d (Tc-- w- /D-EC. P--= -it = R L D) Eat. Cn DCS Plans & Psnz:i = . �. S=.vcC` SV= . e t i i 1 FrOL_l_ & D or J --1; ;qe i l `r j i , S `ri i cz Line i-' chi C nstructicn Notes (grinder rate) LIesicn TMta: per` and deep res _s T'wc -Foot C-- ntCurs Existing & Prores=-"� Drive:+7av & S1o_ces Cut Fcctir, G-0 er,Qurtain Drai nc (-;:sc Iar re OK P&--c & Deep F?cles E, -ca-ted Represantative Of pr-- 'rra.TV ard ex"...arsicr. Exp. nsicn Area; s_:C1vi7; - avitV flC d, C-af -. sip I_ Fst- P -t & D Box Shawn & D-e_ .ilw Douse - No. of BedrecAs ivells & SSDS's w/-in 200 ft. cf r occsed S_�s PrCCX" �y Mei—s & Eocum ;q Hcnse Se` k Necessary (Tic;.t 1ct) House S F-we'_ d "O; -TjTe Oi-..c No F32^ Max. Bends 450 wjcl= .out SF?Da.RP.TICN DIST=\= SPEC!= CN P=N Fields 10' to P.L., Drivewar, L�T-e T- e- zs,Tcg cf 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pit 100' to Strea-ma, Watercour-se, Lam. {8 (inc. e: 15' to Drains O: r-1-- i I, Leader, Foot-inc 35'tc catch L-asin,StOrLT=ain,Dlr:ei waEa—=: 10' to Water Line (pits -20') nitt ^t Cr? i n-a e CvLir —se 50' lnt� S`oLc T.nks 10' fran Found: ticn; 50' to 15' we-1-1 to PL ° SutDI T'SIC a 'j I DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY.CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL��^ PCHD PERMIT # WELL LOCATION Street dress . Town/Village/City Tax Grid Number i WELL OWNER Name Mailing A Li dress e� 1 private O Public USE OF WELL 1 - primary 2 - secondary RESIDENTIAL 0 BUSINESS ® INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM. O TEST /OBSERVATION 13INSTITUTIONAL O STAND =BY 0 ABANDONED 'O OTHER (specify :AMOUNT OF . USE YIELD SOUGHT $ gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE Novo gal ';REASON FOR DRILLING 0M SUPPLY OPROVIDE ADDITIONAL SUPPLY ORE LACE E STING SUPPLY ®DEEPEN EXISTING WELL OTEST OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE GRILLED EIDRIVEN ODUG [:]GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES L,--'NO IF WELL IS LOCATED IN A -REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name -17 �, 0 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY.: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED O ON REAR OF THIS APPLICATION (date 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.. Date of Issue: � 19� Date of Expi rati o ._____ - -. 19— '� -'� Permit ssuing Official White Permit is Non- Transferrable copy: H.D. File Yellow copy: Building Inspector Pink .Copy: Owner 287 Orange copy: Well Driller f I . i C o' l , � \\ �\ � . • I2sv c�.� raw � S�Qr c. TA+.1 K- Lis F � 555Q1,tFuAer r \\ ,d� 1J7 Goth KEG F)IUI"�'D• �� TIIIS IS TO CERTIey ✓ �D�V D�... h } I : + N� pFPtnam County Department oY Health �"�UCTED AS TAT SEWAGE DISPOSAL SYSTEM ��` ' F N 044 Diviai'o�y of.,Environmental Health Serv10e8 �c.H ` 1 WAS INSPEIC�ON THIS PLAN AND THATry, 1iclyj ' �BY ME BEFORE IT THE{ `< SF ' Approved ea tlotec�Yor oo�formanoe with STEM WAS CC'�JTRUCTED WAS COVERED OVER. * 1� le Rules Bmd .ogulatiovs of the _ J-IIE RULES AND,/rREGUL IN ACCORDANCE WITH # Zia D.'- ;PARTMrNT ATIONS THE PUTNAM OI•* HEALTH, OF J am CO Y Healt epart ent. COUP Mac �? N p ze '` - g. re Title A �� ~ • �' I UL. �a swe1t, i a 50 0 1t3 -o , 104 -0 4D o 2 (08 4 5 82 -0 (v!o-o 7 CIV- b 78 -o 84 -4 °J Io5 -b 910.. Io > IZ -b rj8 -0 IZ 12`1 —v 1 - C o' l , � \\ �\ � . • I2sv c�.� raw � S�Qr c. TA+.1 K- Lis F � 555Q1,tFuAer r \\ ,d� 1J7 Goth KEG F)IUI"�'D• �� TIIIS IS TO CERTIey ✓ �D�V D�... h } I : + N� pFPtnam County Department oY Health �"�UCTED AS TAT SEWAGE DISPOSAL SYSTEM ��` ' F N 044 Diviai'o�y of.,Environmental Health Serv10e8 �c.H ` 1 WAS INSPEIC�ON THIS PLAN AND THATry, 1iclyj ' �BY ME BEFORE IT THE{ `< SF ' Approved ea tlotec�Yor oo�formanoe with STEM WAS CC'�JTRUCTED WAS COVERED OVER. * 1� le Rules Bmd .ogulatiovs of the _ J-IIE RULES AND,/rREGUL IN ACCORDANCE WITH # Zia D.'- ;PARTMrNT ATIONS THE PUTNAM OI•* HEALTH, OF J am CO Y Healt epart ent. COUP Mac �? N p ze '` - g. re Title A �� ~ • �' I UL. �a swe1t, i a is r , C o' l , � \\ �\ � . • I2sv c�.� raw � S�Qr c. 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