The URL can be used to link to this page

Home My WebLink About0304DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -1 -52 BOX 4 I1 r �i him Is hr 16 ry 00113 Tax Map Lot N t` 'Subd' Lot N t `` Addreu � j E s r .moo. lost WELL COMPLETION REPORT PUTNAM DEPART ZE VI7 OF '14EALTI-I 317 Z. Uiv;sioll of Enviro'nine6tal Health Services Town Of Patterson Building Dept. Building Inspector John N. Calbo COUNTY OFFICE BUILDING - CARMEL, NEW YORK This report is to be completed by well driller and submitted to County Health Department together with laboratory report of analysis of water sample indicating water is'of satisfactory bacterial quality before certificate of construction compliance is issued. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION OWNER NAME ADDRESS LOCATION OF WELL (No. a Street) (Town) (Lot Number) PROPOSED USE OF WELL BUSINESS LOJ DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL ❑ SUPPLY 11 INDUSTRIAL El CONDITIONING ❑ OP:Ey) DRILLING EQUIPMENT ROTARY COMPRESSED CABLE OTHER AIR PERCUSSION ❑ PERCUSSION 0 (Specify) CASINO DETAILS LENGTH (fu� 5 DIAMETER (inches) god WEIGHT PER FOOT vd LOU THREADED ❑ WELDED' YES ❑ NO I VI CASING YES NO YIELD TEST HOURS G.P.M. BAILED ❑ PUMPED COMPRESSED AIR Jr YIELD (Q.P.M.) WATER LEVEL — MEASURE FROM LAND SURFACE —STATIC (Specify test) DURING YIELD TEST j feet)�� Depth of Completed Well in feet below land surface: SCREEN DETAILS MARE A; lfrNG�M OPEN TO �QUIFER Jleet) SLOT SIZE DIAMETER (Inches) IF GRAVEL PACKEDr Diameter of well including gravel pack (Inches): GRAVEL SIZE (Inches) FROM ( /set) TO (test) DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact. location. of.wsll. with d /etencse,,ta.st lout two permanent landmarks. FEET to FEET If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED DATE OF REPORT WELL DRILLER (Signature) %jr� m d %0 yq b 0 o. N J a�oc Z W / , / %0 yq b 0 o. N J a�oc Z W / , / 0' R'' N. 30 °02 4fi W..90OB ". ;- �' r i N.33 °04 06 µ 164.36 ...N .. - N. 3 9 °ll 08 Cable h ' / h stone y --- �—-___ --- __.. N.59 —_ N59°3e'46 "E -S•" •N.30 °0246 "W_9061' 2500 /66.5 N.j3 405 W. CENTER LINE OiR: FILED AMP Me 1916 CUS`HMAN ( FOUR CORNERS ROAD) ROAD PARCEL << .A _ - 0 31sACRE1 Only copies from the original of this survey morked with on original Certifications here4,gn/fy that this surrey woe p/ of the /ayd surriyar s inked sea / or his embossed seal shall be con- once with the existiC4We of Prrocfics for Load So sidered to be valid true copies. the New York Skfu0ciotion of Prohssional Log Said cerlifications r// run on /y to the person for i Unauthorized alteration or oddilion to o survey mop bearing o licensed is prepared, and ant behol/ to the fit /e company, land surveyors seal is o violation of Section 7209, Sub-Division 2, geney and lending eitution listed hereon, and lo. of the New York Stott Education Low. the lending instiluli Certifications orq not frog Sequent owners or odOitiona/ /nsNtutiens. ROBERT E. BAXTER Q ASSOC. Land surveyors and Planners Underground easems, structures and /or eawo SSDS .AS SUII�T DEMENSIDN Gt -I�.RT G2- 55' G3 - 01 03 - 72` AS GUILT 1LAN z l + s . i e � .. 9 y} s k '.•.t A ya "'ia 4'l �4s �'..� ' �,t��y`J �k�� ",'-.y.. s•+5. , •: � �.... - ,`^ '. 1 -., 4: �. .: is Y^ r• .. +,,.. � ;. `�. f,$ _ t. s a ±'a!f:'i$'•`F � "1 3t x[y ":c y ! pi!,r ';1Y' �,.'�,�� q J n• ' ti � .• 1,. � v {„'� �Tr jYw,`'J 'c'��. ;spFti� tR " <t F3�i6a�.$ws1ss "f ,_tl p:'•!f� �f3 - f �. C .,tr.. •r' � fx. 4 s..�?.s o-,r vas �' t `r Vic. 2,'�ix� �� ik ;:r�' '�� f' ,t � ,,i,•. � t•r +_.�?/ Y k'".� ��.t yy .X�. A•., Asa .r„ "o- .C..,aL ...°4� LT '1-- .••�-_�Y� U „�'. ��e r.', r 2 .:._.`J DEC+ '`.- *. r �t, •v. n. v ra c r -. fi t -.y. , ( } F t .l ?II 4 T, d••� "C.i tt�k•. . li yJ;�.( d. '•1,. ,, •..'°?t :. , '•4., <. ri,h -., -•+ t r_.rr { t 1. f.';?I 5 /„ ] 3,f ,f �1.. 1 ➢LY.i�wi��,. ,,,99;y1� Q �f, z - � ,.. ..:�. �t� •. .. Y't< :;..v � ... .,5 ... �.. . �, � 7 -T.. .�.. -: t'.. :t`.t� •�: ,�. �+14LL ;07� PIT we 1, • �.;;e, ,.�, ..,.., x. f ;.. .. r oS, i r.. y 'o x t. ;r. , tvi�OYY� .. ! 1 ' :, � �.. .a.. 1 � .N. ry r.. ;': - ,r•,.. - ' e y .;t s,. ; h � i...��e ?.. . •$(,,,., � �'� •..a r 1.'. - x4 ,. ; ". f r' rr..` , iz' ,'� - .� , °.0 ,Y �.:r :K Ty'',, ".•.r „. ,1'�' � -e:', .,.z' q .7::t, ^v,r ,ATM P' ��- - � :4' w i Cast y Ilea De ORI(TOWN MEDICAL LABORATORY INC. P.O. Box 99 321 Kear Street Yorktown Heights, N.Y. 10598 245 -3203 LOCATIONS: ❑ 321 KEAR ST., YORKTOWN•HEIGHTS, N.Y. 10598 245.3203 ❑ 201 BUTTONWOOD AVE.. PEEKSKILL. N.Y. 10566 737 -8777 ❑ 495 MAIN ST.. MT. KISCO, N.Y. 10549 666.3335 ❑ STONELEIGH AVE. (NEAR HOSPITAL), CARMEL, N. Y. 10512 278.93: L J LABORATORY REPORT mg/L OACIDITY .................. ............................... ❑ ALKALINITY /�............ .... ACTERIA, TOTAL /mL .........�J . ............ ..............................: BOO. 5 DAY ❑ BROMIDE ..... ........................... ..... ....... :..:.. ❑ CARBON DIOXIDE. FREE .............................. ❑ CHLORIDE ................... ............................... ❑ CHLORINE ................... .....:......................... ❑ COD ........................... ............................... ❑ COLOR ..................... ............................... ❑ CYANIDE ................... ............................... ❑ DETERGENT, ANIONIC ..... ............................... . OFLUORIDE ................... ............................... ❑ HARDNESS ................... ..............4................ ❑ MPN COLIFORM COUNT/ 100 ml ......�� )WT CO LI FORM COUNT/ 100 ml .b t .............. 6 CONFIRMATORY TEST ... ............................... QNITROGEN, AMMONIA ... ............................... ❑ NITROGEN, KJELDAHL ... ..............:................ ❑ NITROGEN, NITRATE ... ............................... ❑ NITROGEN, ORGANIC ... ............................... ❑ ODOR ....................... ............................... ❑ OIL 6 GREASE ............... ............................... ❑ off ............................ ... ............ .... ........ ... C_', PHENOL ....................... ................:.............. ❑ PHOSPHATE (ortho) ....... ............................... ❑ PHOSPHATE (condensed) ... ............................... ❑ PHOSPHATE (total) ....... ............................... ❑ SOLIDS, SETTLEABLE, mt /L ..................... ...... l OSOLIDS, SUSPENDED ... .....:......................... ❑ SOLIDS, DISSOLVED ... ............................... OSOLIDS, TOTAL ........... ............................... ❑ SOLIDS, VOLATILE ....... ............4....:.:...:....... ❑ SPECIFIC CONDUCTANCE ......:....................... ❑ SULFATE ................... ............................... ❑ SULFIDE .................... ......................:........ ❑ SULFITE ..... :............................................. ❑ SURFACTANTS ............ ............................... ❑ TURBIDITY ❑ ALUMINUM ❑ ANTIMONY ❑ ARSENIC ❑ BARIUM .- LAB # Pso DATE TAKEN • • 0S DATE RECEIVED: DATE REPORTED: - 3 SAMPLE SOURCE: REFERRED BY: COLLECTED BY: Lbyo o�.y o s ❑ BERYLLIUM .............................. :................................ ❑ BISMUTH .................................... ............................... ❑ BORON ........................................ ............................... ❑ CADMIUM .................................... ............................... ❑ CALCIUM . •• .. .... ❑ CHROMIUM (tot.) ............................ ............................... ❑ CHROMIUM (hexavalent) ......... ........... ❑ COBALT.. ............ ..... ..................... ❑ COPPER ...............:.................... ............................... ❑ GOLD :............ . ........................... ............................... ❑ IRON ........................................ ............................... ❑ LEAD .............. ...................... ............................... ❑ LITHIUM .................................... ............................... ❑ MAGNESIUM ................................ ..................:............ ❑ MANGANESE ................. ......... ............................... ❑ MERCURY .................................... .......................:....... ❑ NICKEL ........................................ ..............................: ❑ PALLADIUM ................................ ............................... ❑ POTASSIUM ................................ ............................... ❑ RHODIUM .................................... ............................... ❑ SELENIUM .................................... ............................... ❑ SILICON ......................::............ ............................... OSILVER ........................................ ............................... ❑ SODIUM ............................:........... ............................... OTIN ............................................ ............................... ❑ ZINC ...................................... ............................... .. ❑ ....... .......... ................................... .................. ❑ ............................... ............ ............................... ❑ REMARKS: ........ .... . .......................................... e .......... ❑ .................................................... ............................... ❑ .................................................... ............................... ❑ ................................. ................... ............................... ❑ ...................... ......................... ............................... ❑ ..................... .. ............ ❑ .............. ....... ...... ..............................« .... ._....... THESE RESULTS INDICATE THAT THE WATER WASOF A SATISFACTORY SANITARY QUALITY WHEN THE SAMPLE WAS COLLECTED. THESE RESULTS INDICATE THAT THE WATER DID; MEET THE SATISFACTORY CHEMICAL QUALITY OF NEW YORK STATE ADMINISTRATIVE RULES & RECU TIONS, DRIN W R STANDARDS (PART 72) FOR THE PARAMETERS TESTED, � �1 0 f ►' ! , : �.� �� . , .f AT.RPRT N PADOVANI M.T (ASCP). DIRECTOR._ - -- . PUTNAM COUNTY PATTERSON. NEW YORK 12563 Date John N. Calbo •UIIDIMY INSPECTOR Application For Well Permit The undersigned hereby makes application for approval.for the installation of'a well on the property described below. Location of.Provert (street)' Tax Map # Name of Owner l y- o enh—:h u, Name of Contractor f �l �l iZ.L L"41- l >E�FE Source of Water Public i Drilled Dug Spring Ground pelow s:}zow 16cation of proposed installation on property. iWell to house 'Well to Property line Well to septic Building Department must receiv'e.We`11 Log and Water Analysis Contractor Fee $10.00 (sign) Address Town and State JOHN N. CALBO Building Inspector M b PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner sL�l c ►`�,�S • �u ` .�l_eQ_ Address eC` + tstii'- a C i C� a . moc)He /jai <� Located at (Street K'Mskmayj /2c1 Sec . r`j Block Lot ndica e nearest cross ss ree Municipality, fS' c Watershed 61 Did r� SOIL.PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Ruh Elapse Depth to Water Water ve No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches l / /:5v iZ.0 > j 2 1 z;,n 2,:z3 3 i2:3o ,�?, : 9L V j 4 5 (l i /'s3 i20 15 2 i Z' t av Y v r-3 2'? 3 •a-� 3 9.7 3 a 3 V:0 a 5 Notes: 1) Tests to be repeated at same depth until approximately equal. soil rates are obtained at each percolation test hole. A11 data to be submitted for review. 2) Depth measurements to be made from top of hole. v'c1s�� TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. �_ HOLE NO. `y HOLE NO. G. L. 6" 12" 1'8" 1 2`411 3011 36" 1`'h 2 " `t811 54 it 60" 66" 7211 78" 8411 4 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE , BY. Date ✓Yl LZ4 / "Ey DESIGN Soil Rate Used -% MirVl "Drop: S.D. Usable Area Provided veyys t=. No: of Bedrooms _Septic Tank Capacity /000 Gals. Type Absorption Area Provided By �oU L. F.x241' �'j' '— width trench. sa�s�Other Address cc - d'�LE EW ure SIV THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: h 44; k Soil Rate Approved Sq. It/Cal. Checked J, a Date THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: h 44; k Soil Rate Approved Sq. It/Cal. Checked J, a Date