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HomeMy WebLinkAbout0329DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -2 -28 BOX 4 I loom or 1I' ly- Iwo IN I I lI, or r I 00138 i f a FW 0� WELL COMPLETION REFUNI DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH �_ e y` S Office Use Only WELL LOCATION STREET AOURESS: TDWN1VIL VCIIY TAX GRID NUMBER: Crass - -� WELL OWNER NAME' ADDRESS: e� ��- ,Q ` � �� Ac rSc PRIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED O BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING EI PLACE EXISTING SUPPLY TEST /OBSERVATION [ADDITIONAL SUPPLY fNNEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL DEPTH DATA ' f� WELL DEPTH 6 ft. Of Wj � STATIC WATER LEV ^.r_ ft. DATE MEASURED `i DRILLING EQUIPMENT ❑ ROTARY TCOMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH __s_ ft . MATERIALS: STEEL 0 PLASTIC ❑OTHER LENGTH BELOW GRADE Q9 ft. JOINTS: ❑ WELDED THREADED ❑ OTHER DIAMETER in.' SEAL: ❑ CEMENT GROUT ❑ BENTONITE OTHER WEIGHT PER FOOT lb./ft- DRIVE SHOE YES ❑ NO I LINER: G YES ONO SCREEN DETAILS DIAMETER (in) 'SLOT S LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST S ❑ No HO P SECOND I GRAVEL PACK ❑ YES ❑ NO GRAVE SIZE: DIAMETER OF PACK in. V TOP DEPTH ft. BOTTOM OEM tt. WELL YIELD TEST If detailed pumping M9HOO: O PUMPED 1 tests were done is in- & COMPRESSED AIR , formation attached? O BAILED ❑ OTHER ; O YES O NO WELL LOG it more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SuRFAcE water Bear- ing well Dia- rteter FORMATION DESCRIPTION CODE tt. ft WELL DEPTH It. DURATION hr. min. ORAWOOWN it. YIELD gym. Land Surface � c / 1 6V , 7ojn e. WATER I&EAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES ON 0 STORAGE TANK: TYPE CAPACITY GAL. PUMP IMF RMATION, TYPE "�Z � MAKER MODEL f �e CAPACITY DEPTH VOLTAGE HP WELt.oLRl�EA�tA HYATT &SONS, INC. DATE AA tt�j K %6 ADDRESS Well Drilling SIGid URE fete' 311 4�i R, 2 vnBox �171A Alt , RATT!- ,..,O:. IN4Ev .,I�:l. i25 &3 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'i�_09-� Owner or Purchaser of Building 0 Building Constructed by 0L�-,) =�,� Location - Street Munibipaality Building Type 10 Se ctioa Block Lot q o'C(.� Subdivision Name Subdivision Lot # GUARANI OF SUBSURFACE SEWAGE DISPOSAL SYST&M 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 swage 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 'F L (3 19 `t 2 Signature •� QTitled 44a-,.— General Contractor (Owner) - Signature Corporation Name (if Corp.) Uwvj Corporation Name (if Corp.) -�v�jo ' "-� ' Address / T- o- 73o k a Z cx"-� -ee-So �� N. Address rev. 9/85 mk DUTCHESS COUNTY PEPARTMEWT OF HEALTH ENVIRONMENTAL NVIRONMENTAL HEALTH LABORATORY ,- 387 -391 MAIN MALUPOUGHKEEPSIE NE1N'YORK 12, 601 TELEPHONE # (914) 431 1,68WFAX,# (914) 431 1537 - - ENVIRONMENTAL- LABORATORY APPROVAL PROGRAM ;CERTIFICATE # 101$9 �� y " : F LAB FORWARD REP TO (pLEASE'PRIN1� TYPE OF FACILITY' =NAME : < ❑ .PUBLIG,INATER SWPPLY. ,rIVATE RESIDENCE d STREET ADDRESS WASTEWATER TREATMENT FACILITY . 5 =E f `C,.I*' c� % �` ,{ s: 3 0 BEACH CITY ST ZIP �❑ OTHER ry sOW Np: • 2 ' FACILITYNAM cl � - u + !a PHONE . 0 MONITORING SAMPLE SAMPLING.POINT :' ­ ❑ CHECK SAMPLE SOURCE: DRINKINCrWATER, ; ❑SURFACE WATER, ❑. WASTE WATER; :.OTHER: l] FREE TREATMENT. ❑ CHLORINATED PPM ❑ 'COMBINED ; ❑OTHER TOTAL. ❑- DCHD`PERSONNEL' COLLECTEDBY. -� 1-i.s� . a:: TITLE: . ❑NONDCHD "PER$ONNEC ` DATE SAMPLED TIME ICED f1/ ��,. i r❑ 0 1�f✓�`J /JI AM 77 MFT : ❑ MPN TOTAL COLIFORM COUNT i PER 100 `ML Cl MFT ❑'.MPN FECAL- COLIFORM COUNT PER 100 NIL E MFT FECAL STREF. COUNT PER 100 ML Q STANDARD PLATE COUNT PER 1 ML; - MISC. _ INVALID TEST RESULTt WITHOUT COUNTY THESE RESULTS INDICATE THAT THE.'WATER•.SAMPLE 0� DID NOT � DRINKING u iMEET SATISFACTORY SANITARY - QUALITY FOR ❑SWIMMING , -; = ❑ NASTEWATER EFFLUENT WHEN oTHE 'SAMPLE WAS COLLECTED FOR f �' INFORMATION CONCERNING"' UNSATISFACTORY SAMPLES PLEASE CALL THE HEALTH DEPARTMENT AT -- EI AP CAB Nei, ifl1$9 6ACTERIOLQ ICAL EZANINATIDIf ,OF AT�� ` CuVTOMER" S 'LAB DIRECTOR P7 VA fl-IIS IS TO CERTIFY THAT THE SEWAGE •DISPOSAL SYSTEM WAS CONTRUCTED, AS INDICATED ON THIS PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT WAS COVERED OVER. .,THE 'SYSTEM STEM WA -IN-ACCORDANCE WITH ALL THE *R D. REGULATIONS OF THE NAM COUNTY D TMENT . OF HEALTH. 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DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE S,IX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # P 3�,7 WELL LOCATION Street Address . .� Town Village City Tax Grid Number 5= WELL OWNER jIgme Mailing A ress C.Ptivate O Public E OF WELL primary` 2- secondary GISIDENTIAL 0 BUSINESS 0 INDUSTRIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O FARM- Q TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify Q AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED . /EST. OF DAILY USAGE gal REASON FOR DRILLING 13 REPLACE EXISTING SUPPLY ®MEW SUPPLY (NEW DWELLING ❑ TEST /OBSERVATION 13. ADDITIONAL. SUPPLY 3 DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE M16RILLED DRIVEN [:]DUG GRAVEL 0 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 �! Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:. YES ��TO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & RCES OF CONTAMINATION PROVIDED N SEPARATE SHEET (date) s 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 thirt3c (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 dril operations be contained on this property and in such a manner as not to degrade or of erwis contam ate surface or groundwater. Date of Issue: 19 01 Date of Expiration Z 19 413 P mit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller 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 Of_ WELL LOCATION Street Address L Town Village City Tax Grid Number .. WELL OWNER Name Maili Address rivate D Public USE OF WELL 1 - primary 2 - secondary &RESIDENTIAL D BUSINESS D INDUSTRIAL DPUBLIC SUPPLY QAIR /COND /HEAT PUMP 0ABANDONED O FARM. ❑ TEST /OBSERVATION . p OTHER (specify, b INSTITUTIONAL ❑ STAND -BY .13 AMOUNT ' OF USE YIELD SOUGHT l gpm /# PEOPLE SERVED EST. OF DAILY USAGE 40 01 REASON FOR DRILLING ❑ REPLACE EXISTING SUPPLY D TEST /OBSERVATION Q ADDITIONAL SUPPLY nlnfw SUPPL Y N DWELLING 11 DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE 12DIILLED 1DRIVEN []DUG 0GRAVEL. 0OTHER 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 Ta ia. 7) Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES i/ NO NAME OF PUBLIC WATER SUPPLY: TOWN /VII: /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: .�► LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED SEPARATE SHEET (date) s ` 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 s La manner as not to degrade or otherwise conta 'nate surface or groundwater. Date of Issue: 19 Date of Expiration Permit is Non - Transferrable 3/89 19� Permit Issuing 0 icial White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller No Lc rees cm ,�- - I Cam_: c= I- C-.� L_4 _tip `c T`G_ w j — - r e T Far= LG� l.0 ►_ i� � __ _�.r..- J- - !C C= C:: (LCLc C- I`TV. CLE_...�- ."'C:.� inn C`_. � _ r_C.i t TC N F' ci—S - 10 1 t= _ . 20' to f 100' tL %I1; D_r._C_Df loo, to Str- =rid ."TL 1 L'C L�L_inc tom' ACC 10, to ;vc = -r Lam_ = (c1 s -20 ` ) 1U i _ CLr'_� =__ i 5 ` t= 1 =` SLl t_ _ PUTNAM COUNTY DIVISION OF ENVIRONMENTAL HEALTH SEMCES DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM 7 FILE NO. Owner 12 1 A,,A Address Located at ( Street) COL-,-, 'Orr 311 (O Block _ Lot S (indicate nearest cross street) Municipality 'R>et�dA Watershed SOIL PERCOLATION TEST DATA RBQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre-Soaking— 1821 Date of Percolation Test ez) Run No. Start -Stop Elapse Time Min. Depth to Water Fran Ground Surface Start Stop Water.Level In Inches Drop In Soil Rate Min /In Drop Inches Inches Inches 1 Z93& 2 _ �� 130 � �g Z9 g1 131 !� _ 3 e 3r) aU 4 0 , 36 1v - -- -9 Ilk 5 2 0 vU <3© /7 �!�' 4 % 3 �' 17 3 '30 e.) 4 5 1 2 3 4 5 G -AIM 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 submitted for review. 2. Depth measurements to be made from top of hole. rev. 9/85 DESIGN Soil Rate Used A= D Min/1" Drop: S.D. Usable Area Provided e-90epco �5,`'°' No. of Bedrooms y Septic Tank Capacity /0r?,0) gals. Typ Absorption Area Provided By L.F. x 24" width trench Other /% �gp4a---� zj x>eor, 4 ;- Signature Address //1�.�' �� SEAL ;�ttU w+�: Giles /l/' fool v% a�`"o 0, 048 p � THIS SPACE FOR USE BY HEALTH DEPART ONLY: Soil Rate Approved I sq.ft /gal. Checked by Date TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. ( HOLE N0. HOLE NO. G.L.�y��G 2' 3' 1 / y/ 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used A= D Min/1" Drop: S.D. Usable Area Provided e-90epco �5,`'°' No. of Bedrooms y Septic Tank Capacity /0r?,0) gals. Typ Absorption Area Provided By L.F. x 24" width trench Other /% �gp4a---� zj x>eor, 4 ;- Signature Address //1�.�' �� SEAL ;�ttU w+�: Giles /l/' fool v% a�`"o 0, 048 p � THIS SPACE FOR USE BY HEALTH DEPART ONLY: Soil Rate Approved I sq.ft /gal. Checked by Date