Loading...
HomeMy WebLinkAbout0327DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -2 -26 BOX 4 Sl ELF J L r.. T � '1 T ir F . L' it 00136 ���,. r. =: `:���: i' -. �: 6 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 WELL PCHD PERMIT #fic F s2- WELL LOCATION St et Address Town/Village/City Tax 3' Grid Numb r WELL OWNER Name M iling Address 041fivate O Public USE OF WELL 1 - primary 2- secondary � ,.,,�� &1 SIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP- O FARM O TEST- /OBSERVATION O INSTITUTIONAL O STAND -BY 0 ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE�0Bal REASON FOR DRILLING ❑ RECCE EXISTING SUPPLY O TEST /OBSERVATION 13 ADDITIONAL SUPPLY W SIMPLY (NEW- DWELLING O DEEPEN EXISTING WELL DETAILED' REASON FOR DRILLING WELL TYPE 05RILLED DRIVEN O DUG GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES 4,---N--O IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name 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 & OURCES OF CONTAMINATION PROVIDED SEPARATE SHEET � t (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 thirt3r (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: 19 Date of Expiration 19��_ Permit Issuing Offic al Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PURPIM CXNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL BEALTH SERVICES DESIGN DATA SHEET- SUBSUFACE SES+VAGE DISPOSAL SYSTEM FILE NO. Owner• Address 0 Located at (Street) 6ee. 10 Block_ Lot ( indite est cross street) Municipality �5,�.0 Watershed SOIL PERCOLATION TEST DATA RDQULRED TO BE SUBMI= WITH APPLICATIONS Date of Pre- Soaking I L� Date of Percolation Test r? 126 HOLE N(VBER c= TDEA- PERCOLATION PERCOLATION Run Elapse Depth to Water Fraa Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches / 2 0 , 1 Z� �l� �� '7 3 3 4 5 2 2-1 12- 3 C — --5 31 40 4 5 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 sutmitted 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 ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. / HOLE NO.. HOLE NO. G.L. � r 2 3' r 4 6' \ r 7' 1� 8' 9' 10' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED 1�Lf�vlZ4't0 INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: - DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided _ M)±j,�- No. of Bedrooms Septic Tank Capacity gals. Type !9 Absorption Area Provided By L.F. x 24" width trench Other Name /� r����'.cSi9 ��� Signature ' Address �9X 2-4�3- Ste,��` �ry� THIS SPACE FOR USE BY HEALTH DEPARTNP ONLY: Soil Rate Approved sq.ft /gal. Checked by Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date f A 9 Re: Property of Located at, n\ J C;. (T) Block Lot Subdivision of Subdv. Lot # Filed Map # `Z, C) Date �2 T. MICHAEL DALY, P.E. Gentlemen: CONSULTING ENGINEER P. 0. BOX 243 This letter is to authorize SHENOROCK, N_ V_ 10587 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, ' fined Q? (° Countersign ec .!'� Owner of Property P.E., R.A., # Address T. MICHAEL DALY, P.E. Address UU14SULTING ENGINEER P. 0. BOX 243 SHENO.ROCI:, f'. , . �r Telephone Town 9.78- _ 6 SZ Telephone Fit- D17T.`�7CJ CF NO T E 'a' (7C ) Ia ( 2 = = - cz 1==-=- _ - - -4 ..�r12" r = Pit &`D� cc cw: __ C__=- - ' t L ' & No -+ —'_ r- Tr^ C= l.l�i20f to �= - '�''-� �,r-c;c?•�c�', Lam_- - - - d° ✓I� I t. ' G._a.�'i 1i'G : =rte 'lL•.= r—..G (- C_ �._ La toe I - -�-- -- - 35' =__ I I � k I,EAGC -2 � fu�(icJ6 17rcDiti1 PIS�ripl�� TU � pfavr- W eL . Na '95aA' WIT4I�1 No ' 1,OT' p i 1150 GA(, 4 11514 Cb+sY HAVIER �(Amox � ..- PIzOP �4� oI $EsD (MIR) 9? F OI.OV 55 VH oyr) 5� DH-J . WITHI1A ZA u <t Cl V, ry dYQn[J?C wxtio41 }'I!5P-6 `W-317 10 /Mwlio 6.,% +T1ot4 osc Dew' iCy r How ri� ii 2lnnat� , 12y ? OF AIL 72'I SAI.1oY j,OAM WITA CLA`f I,EAGC -2 � fu�(icJ6 17rcDiti1 PIS�ripl�� TU � pfavr- W eL . Na '95aA' WIT4I�1 No ' Separate Sewerage .System built :by ' / � � Address /� 1 Consls4ing of O Gallon Septic Tack and Lo Water .Supply: Pubpc Supply. From (( Address or. ✓ Private Supply Drilled by Address -- 7, )F l Q ;gam Type AL - Has Eroslon' Control_ Been Completed? Number of Bedrooms Has Garbage Grapder•Been Installed? Other Bequiremente I'certify:,that, the syet"'(s) as listed 'serving the above premises "were constructed essentially.as shown he plane of the completed work ( copies of whicK ar'e atteched),:and in accordance with the standards, rules and regulations, n acc rdanoe th fil plan, and the permit issued by the Putnam County'Departmeni Of HHl1ealth. Date'' '� V Certified by P.E.R.A, ? Address License No. Any person oca upytng premims served by the above system(s), shall promptl tie such action as maybe, necessary to Secure the correction of any - unsanitary conditions resulting from. such, usage; •Approval of, separate sews cyst n► shall become nul void at soon as . a..pubtc:. sanitary p1N1r becomes available and the approval of the privats`water..supplY siialPbeeorime I n `v when a ,pub, a •supply becomes available. Such approvals are ;subject to modi leatiop /or change when, in the lud9ment of the o of M h/su r ocatlon, modlflcatlon or change Is Mces r , Oate��1 'y BY Title j t K PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 6 �ia�ra Owner or Purchaser of Building n Building Constructed by Location - Street Municipality Building Type 10 e5 Sectim Block Lot 'TW &'d A- Subdivision Name Subdivision Lot # GUARANTEE OF SUBSURFACE SEV&GE 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 "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 1 day of i � 1990 pj,v�w, 21-�)� General tract r (Owner) - Signature Corpora ion Name (if Corp.) ess rev. 9/85 mk Signature v C Title - A,�- , o ZL2 Corpora n Name (if Corp.) Addfe!i(s AA// Yorktown Medical Laboratory, Inc. 321 Kear Street Yorktown Heights, N. Y. 10598 (914) 245 -2800 Director: Albert H. Padovani M. T. (ASCP) r PETER O'HARA P.O.BOX 282 PATTERSON,NY. 12563 L J LAB # t )4C)1 `5 Date Taken: 11/5/90 Time: 11. Oam Date Rc'd: 11/5/90 Time: ll -, 55am Date Reported: tir)II n p 1990 Collected By: P.©fHara PO /Client # Referred By: Sampling Site: Kitchen Tap Lot #8, O'Hara Subdivision Patterson.NY. REPORT ON THE QUALITY OF WATER Phone ( 914 ) 878 -4221 INORGANICS (mg /L) MICROBIOLOGICAL 100mL _ 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 _ Standard Plate Count ( CFU /1 mL) Membrane Filtration Method Total Coliform 4 Fecal Coliform _ Fecal Streptococcus Most Probable Number Method Total Coliform Fecal Coliform Fecal Streptococcus Presence /Absense (PA) Total Coliform P A PHYSICAL/MISCELLANEOUS KEY FOR TERMINOLOGY _ pH (S.U.) ,Color (Units) Conductance (uhms /c) _ Odor (TON) _ Turbidity (NTU) CFU = Colony Forming Units IT = < = Less Than GT = ) = Greater .Than NA = Not Applicable SA = See Attached TNTC = Too Numerous To Count Other: REMARKS COMMENTS For La b se (For Lab Use) SAMPLE TYPE: (Check One) Potable _ Non - potable OUTGOING: (Check Each) HNO —_ HC13 _ H2SOLL _ NaOH _ ZnOAc Na2S203 Other: INCOMING: (Check Each) LE 40C GT 4 /ICE 200C _ GT 200C _ pH LE 2 _pH GE 12 Other: NYS FLAP #10323 THESE RESULTS INDICATE THAT THE WATER SAMPLE AS) (WAS NOT) (NA) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO UkE YORK STATE PUBLIC DRINKING WATER CODES, FOR THE PARAMETERS TESTED, AT OF SAMPLE COLLECTION. THESE RESULTS INDI ATE - T THE WATER SAMPLE (DID) (DID NOT) (NA, MEET THE SATISFACTORY CH CAL`,( LITY STANDARDS OF THE NEW YORK STATE DRINK- ING WATER CODES, FORTH PARAMETERS TESTED, AT THE TIME OF SAMP COLLECTION. X/ RAU M 7 /87(Rvsd1 /90)RWE Albert H. PadovanM—, . (A GP), Director .t W 0 WLLL 1.,Urir, i Z11Un nr,rUnt DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH © Office Use Only 16 -3 -- WELL LOCATION STREET AOORESS: TOWN/VILLAFALICIFY TAX GRID NUMBER: t �'�Y 60 WELL OWNER NAME: ,I ADDRESS: ¢e c /7 fiG PRIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary LVRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT _ ~ gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE �0 0 gal, REASON FOR DRILLING NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA ' WELL DEPTH /�I'() ft. I STATIC WATER LEVEL ft. DATE MEASURED /d V 0 DRILLING EQUIPMENT ❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING, L>7 OPEN HOLE IN BEDROCK ❑ OTHER CASING TOTAL LENGTH ft MATERIALS: STEEL ❑ PLASTIC . ❑ OTHER LENGTH.BELOW GRADE ft. OR JOINTS: ❑ WELDED YTHREADED ❑ 9THER DETAILS DIAMETER, — in.. SEAL: ❑ CEMENT GROUT ❑ BENTONITE 90TH R WEIGHT PER FOOT Z7 Ib_ /ft. DRIVE SHOE YES ❑ NO I LINER: ❑ YES GVNO SC EEN DIAMETER (in) SLOT SIZE LENGTH (It) DEPTH TO S REEN (It) DEVELOPED? DE IL S ST YES ❑ NO HO RS SqC0Vd GRAVEL PACK YES ❑ NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH ft. 8640M DEPTH It. WELL YIELD TEST It detailed pumping MVHOD: ❑ PUMPED tests were done is in- V COMPRESSED AIR , formation attached? O BAILED ❑ OTHER i ❑ YES ❑ NO 1P/ELL LO Git more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- ing V!eIt D'a- meter FORMATION DESCRIPTION cooE. ft. ft. WELL DEPTH It. DURATION hr. min. DRAWOOWN It. YIELD 9Cm• Surlace �, , WATER CLEAR TEMP. QUALITY O CLOUDY HARDNESS - O COLORED ANALYZED? OYES ❑ NO ANALYSIS ATTACHED? O YES ❑ NO STORAGE TANK: TYPE CAPACITY GAL. PUMP IHFDRMATION TYPE �vl3 CAPACITY MAKER GdUI -,� DEPTH MODEL VOLTAGE�LZOHP 2 ALBERT MMH oatE YATT &SONS, INC. ADDRESS SMAXTURE 1 Well Drilling , Rte, 311 R. R. 2 Box 171A PATTERSON,: NEW YORK 12563 � tM� kxA-TIM A, A5 +-Iz- P!Cfl 106 ve a alf, ,--7777 THIS IS TO CC y'!HIVI THE SE\:,'A(-;F DI—e-l""ALSYSTEM WAS CONTW.(—iI4') il.S INDICATED ON 'I HIS A", "HAT THE SYSTCM !,!,SPL�CITD BlY IMC M-IORF IT OWEVIM (,)VM TAr, v,,,S co �;s,I.-RLJC'I'J'--D IIN ACCORD 'CORDMN�,:L VVIT11 ALL THE RULt,-'.S AND RliGULATIONS OP TILE FUT.�"A.N! f.Ml*," DEPARTMENT OP HEALTII. Vi =1�. =�� -4e; � /100 kxA-TIM A, A5 +-Iz- P!Cfl 106 ve a alf, ,--7777 THIS IS TO CC y'!HIVI THE SE\:,'A(-;F DI—e-l""ALSYSTEM WAS CONTW.(—iI4') il.S INDICATED ON 'I HIS A", "HAT THE SYSTCM !,!,SPL�CITD BlY IMC M-IORF IT OWEVIM (,)VM TAr, v,,,S co �;s,I.-RLJC'I'J'--D IIN ACCORD 'CORDMN�,:L VVIT11 ALL THE RULt,-'.S AND RliGULATIONS OP TILE FUT.�"A.N! f.Ml*," DEPARTMENT OP HEALTII. Vi 10' q I/ do �21505 /P-tnaj�VTqeqqV,ent of Health Divis11 1 1 ion of Environmental Health Services A d as noted for conformance with PrDv c 31)-elle Rules and Regulations of the At y Health Department Signature D. A5 WIL-T Fr:;:SK O'� pvl"Iod =1�. =�� 10' q I/ do �21505 /P-tnaj�VTqeqqV,ent of Health Divis11 1 1 ion of Environmental Health Services A d as noted for conformance with PrDv c 31)-elle Rules and Regulations of the At y Health Department Signature D. A5 WIL-T Fr:;:SK O'� pvl"Iod