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Home My WebLink About0244DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 5. -1 -4.1 BOX 3 00053 16 ar 00053 �1gA9 a ►e T DEPARTMENT OF HEALTH Division of Environmental Health Services COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL W-39' . PCHD PERMIT # IS'WELL SITE SUBJECT TO FLOODING? YES NO IF;WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name ALBERT M. HYATT & SONS, INC. Address: n ,IS PUBLIC WATER SUPPLY AVAILABLE --��{{ R.R. 2 Box 171A 1��ON, NEW YORK 12663 YES NO OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: `•LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION ON 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 s.hall: Date Date 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. of Issue: /257 19 of Expiration: 19 °� O ermit Issuing ffi a Permit is Non- Transferrable 2/87 White copy: H. D. File Yellow copy: Building Inspector Pink Copy: Owner Orange copy: Well Driller Street Address Town/Village/City Tax Grid Number WELL LOCATION i M ailing Address rivate WELL OWNER ;, -r V� -1-�A c ` O Public USE OF WELL / [N RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED 1 - primary O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify secondary O INDUSTRIAL C31NSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 6�Oga1 REASON FOR 0 W SUPPLY OPROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION ` DRILLING PLACE EXISTING SUPPLY O DEEPEN EXISTING WELL .:° ;DETAILED ; ; i iG 7,0 4, ' y -��' -- REASON FOR S DRILLING WELL TYPE DRILLED DRIVEN DUG GRAVEL OTHER IS'WELL SITE SUBJECT TO FLOODING? YES NO IF;WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name ALBERT M. HYATT & SONS, INC. Address: n ,IS PUBLIC WATER SUPPLY AVAILABLE --��{{ R.R. 2 Box 171A 1��ON, NEW YORK 12663 YES NO OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: `•LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION ON 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 s.hall: Date Date 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. of Issue: /257 19 of Expiration: 19 °� O ermit Issuing ffi a Permit is Non- Transferrable 2/87 White copy: H. D. File Yellow copy: Building Inspector Pink Copy: Owner Orange copy: Well Driller WL' LL UUr1C'LLI IVLV rllzrual �, ►� DEPARTMENT OF HEALTH Division Of Environmental Health Services ,r�i-• is 4 I�r PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET ADDRESS. TAX GRID NUMBER: J WELL OWNER NAME: ADDRESS: �y , GG <� o :� PRIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary RESIDENTIAL O PUBLIC SUPPLY ❑ IR /C)ND./HEAT PUMP O ABANDONED O BUSINESS O FARM ❑ TEST/ OBSERVATION O OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL 0 STAND -BY ❑ MOUNT OF USE YIELD SOUGHT _S__ gpm. /N0. PEOPLE SERVED / EST. OF DAILY US4GE e�OG'gal. REASON FOR .DRILLING O�4EW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST/_QBSERVATION 19 REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft. �0vu1�� STATIC WATER LEVEL ft. DATE MEASURED' DRILLING EQUIPMENT O ROTARY eCOMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑SCREENED O OPEN END CASING, OPEN HOLE IN BEDROCK O OTHER CASING TOTAL LENGTH ft. MATERIALS: IKSTEEL O PLASTIC ❑ OTHER LENGTH.BELOW GRADES ft. JOINTS: O WELDED drTHREADED ❑OTHER DETAILS DIAMETER 6 in. SEAL: O CEMENT GROUT ❑ BENTONITE 00THER WEIGHT PER FOOT lb. /ft. DRIVE SHOE JKYES O NO LINER: ❑ YES RNO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (f t) . DEVELOPED? FIRST ONO HOUR SECOND GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH tL BOTTOM DEPTH It. WELL YIELD TEST If detailed pumping MQHOD: ❑ PUMPED tests were done is in- COMPRESSED AIR formation attached? ❑ BAILED ❑ OTHER ; YES ONO WELL LOG It more detailed formation descriptions or sieve analyses are available. please attach. DEPTH FROM SURFACE Water Bear- I�g Well Ole meter FORtdATtON DESCRIPTION CODE_ ft. ft: WELL DEPTH It. DURATION hr. min. DRAWOOWN ft. YIELD gpm. Surface ,� �%�CL t� ' ,0 I G - WATER VICLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? OYES ❑ NO ANALYSIS ATTACHED? KYES ONO STORAGE TANK:" TYPE k'rad / CAPACITY 5� GAL. PUMP INFORMATION TYPE—SA 6 Me- rs> 14 �t` CAPACITY MAKER G►4��ps 6 ' DEPTH _ MODEL %t ()S T VOLTAGE %iP WELL DRILLER NAME DATE ALBERT M. HYATT & SONS, INC. �S ADDRESS SI0*7URE Well Drilling Rte. 311 R.R. 2 Box 171A 1 �dy' PATI'ERSON, NE.W YORK 12563 �'� FA P.O. Box 8298, New Fairfield, Ct. 06812 (203) 746 -3273 WATER SYSTEMS ANALYSIS REPORT OF WATER ANALYSIS SOURCE we//. Date collected 51�2f R9 Time 1 Clam Date analyzed 5120/89 Time ,200M RECEIVED AT LAB Time 1 1 am Lab. # 89 -474. Collected by GR PHYSICAL Temperature °C 12 Turbidity 2 CHEMICAL CHLORIDE (asNaCl) 4.'0 mg 11 HARDNESS (asCaCo3) 70.10 mg /1 ALKALINITY (CaCO3) 40.'0 mg /1 NITRATE (No3) 0.11 mg /1 TOTAL DISSOLVED SOLIDS 90.10 mg 11 TOTAL IRON pH AMMONIA (NH4) SULFATE (So4) LAS (detergent) BACTERIOLOGICAL 0_.RO mg /1 7_1 0.,0 mg /l 2.,0 mg /1 0.,0 mg /1 Reg. No. 0427 Environmental Chemists Owner . L. Address .4tngP t^,nnnh Rd, Y City& State Patterson N-Y., Color 0 APHA units Odor none U.S. E.P.A. GUIDELINES 250.0 mg /1 above 150.0 mg /l considered hard water None 10.0 mg /1 500.0 mg /1 0.30 mg /1 6.4 to 8.5 250.0 mg /1 0.5 mg /1 COLIFORM BACTERIA / 100 ml 0 by membrane filter technique. This value for well should always by Zero. RECOMMENDATION Water is bacteriolo ota is not potable Certified correct boratories The above results are only valid for the date and time on which the sample was collected no guarantee is made or implied as to future water quality. There maybe some elements or compounds that were not analyzed for that may make the water unpotable. We assume no liability for the use of these results. mWater Systems Analysis 0 OWNER'S NAME SITE LOCATION PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES mcm A -Ze 66 PERSON INTERVIEWED I PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER Re ! 6 PHONE .1tl g '� � �, e� Yo 7 REGISTRATION # Pro (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 subui.ttal of proposal from licensed professional engineer or registered architect. - Goo n, cry -&-a -n d W (fi %/ -,w Proposal approv u Proposal Disapproved Inspector's Signature & Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Suh fission 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 d. System description (e.g., 1250 gal. concrete septic tank, drywalls surrounded by one foot + gravel). e. Installer's name and number. pate (e.g.,house corners). three precast 6' diam. x 6' deep 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 Z— vA .s TITLE GATE OOPZ,ES: %bite (PAD); YeUcw (An BI); Pink (Applicant)