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HomeMy WebLinkAbout0590DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -1 -54 BOX 7 00590 T.TTT T dl^MMT VM-r^M DVDnDT WP�LL l,Vl'irLL' 11ULV iwl Viii 0., DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET ADDRESS: 7EWN19l10E77CI1y 7773 TAX GRIO NUMBER :— Ilevon ®n (� //� _ e . P 6 4 WELL OWNER NAME: ADDRESS. C.G c c- <, PRIVATE 10PUBLIC USE OF WELL 1 - primary 2 - secondary RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED O BUSINESS ❑ FARM O TEST/ OBSERVATION ❑ OTHER (specify) O INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT --5— gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE d6Q gal. REASON FOR DRILLING eNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY 0 TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH J ft. STATIC WATER LEVEL � ft. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY YCOMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE O SCREENED ❑ OPEN END CASING: OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH ft MATERIALS: OdSTEEL ❑ PLASTIC O OTHER LENGTH.BELOW GRADE tt JOINTS: O WELDED 9THREADED O OTHER DIAMETER in. SEAL: O CEMENT GROUT IYBENTONITE O OTHER WEIGHT PER FOOT �' lb,/ft, I DRIVE SHOE 16YEi ❑ NO LINER: OYES P-f NO DIAMETER (in) 'SLOT SIZE LENGTH (ft) D H TO SCREEN.(ft) DEVELOPED? DETAIL FIRST ❑ ES 0 N HO GRAVEL PACK ❑ YES ONO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH -ft. BO M DEPTH It. WELL YIELD TEST 11 If detailed pumping METHOD: O PUMPED tests were done is in- COMPRESSED AIR , formation attached? O BAILED O.OTHER ; ❑ YES O NO WELL LOG It more detailed formation descriptions or sieve analyses are available, please attach. EPTH FROM SURFACE water Bear- ing Well Dia- meter FORMATION DESCRIPTION COOE, It. WELL DEPTH It. DURATION hr. min. DRAWDOWN It. YIELD gFm. Surface 7 In S ,425 (95 C WATER IdCLEAR TEMP. QUALITY O CLOUDY HARDNESS ❑ COLORED ANALYZED? O YES O NO ANALYSIS ATTACHED? ❑ YES O NO STORAGE TANK: TYPE U CAPACITY 9 GAL. PUMP INFORMATION ,+ TYPE 5� �is�� /E + CAPACITY ��'�' MAKER �` u n i� D f MODEL %� �1�" 4�'� VOITAG -' > HP V► LL DRILLER NAM GATE LBERT M. EfiYATT &SONS, INC. cc j L�Z ADDRESS Well Drily" 5IGFVMRE �I,4 � ,- Rte. 311 R. R. 2:,f_; _ 171A PATTERSON, NEW; =YO, 12568 ,/` a:.�o. FDTr � � 6a� ?oti -oF Foo fi�G _- 13WI E' 5OX DE5- 5 NOT TO 000Om=cz)OO uoTES'. 0 0 O O 0 0 0 0 O O o O i. COLICCE-rE 4000 ?5.1.Q Y.6 DAYS. 0 0 0 o L. eEILI FOeCEO WrrN tit =3 F-oD. WA9GON°ITiZVGTCO.tN AL' ItA WITH aw 3. 4" PECFOC6TED PIPE C4Sr IQ PLAC£, ATPttfNAm omwTY t7t w of, "eAI.TH 4. N -IO L0.&OIQS. 0 0 0 0 5. -M- GALLECIES -0 66 iU--fULLM Lb.VEL 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 Au15tLE0 A" PIPE,. I CD `.1_ B B B B BB as Ba G as as :aa aaGa aeaa(a a ff III rl �- Vi' Tb 17e GuoEo L. o. TAI- c,���r =ey ac -jv6C-,w-!.um UCrr TO 5CAL-E :PfrON :NGN i0 juNGTION A 130x OIj I.OvJER . TIGH1 SOINT 1 FINISHED GRADE RG'MOVABLE GOVER iv iI,ET 2 (TYP.) u OUTFLOW 1 4"706 HI6,HIJ4 1/4* MINI. GONG. FOOTi NG vrloN 5EGTION 'A-A: NCH JN6 -fION -BOX DETAIL NOT i0 SGAt -C�- it S TAKEN Pl20M suY-VeY fV- el°AKeO aY 15urJIJeY ASWO. LAST t7AiV17 MAY Sly 41`10 2. TH19 I9 TO Gc42111!"f -(H � THG yGWAGe 0t9f49At 9f9Telv1 N9TRiJGTCt� Ah INOIOATP.i? G+tJ TNt9 WV THAT THE 9Y7TGM WA9 tWgs' 9i bt8 OeFORe . IT WA %GflVBt2t`AOVorf97E1�i WA9GON°ITiZVGTCO.tN AL' ItA WITH aw °1fAWVA}2p ATPttfNAm omwTY t7t w of, "eAI.TH AW THI NEN1 YOit ftI'AFLTMr-NT Ot?tdt%ALfH- . > OxISTl No S�. TAM ,,SSG /a CAA G�C s G r 6g�.P qL R 6 °tc rf, NOTES: I. HOUSE F WOI,L I-OC a e.2Nk L�EVpN • �-4v AS - E UILT SGAI,E I "= 4O" hq0 �J80 fP ea. 579.< IN V. -g7G .70 KNOCKOUT IL - 3,5'UiA INLETS i FINISHED C>RADE SDA.OU71 ETs REMOVA6I.E COVER q'e� Gg:1,10 Puc I ' FROM QW11C \9 TANK �OOrrnIG 1 G: NG. F ✓DTI N� 13AFFt,�, 5OX Db- 5 NOT TO 66ALE 0 0 0 0 0 0 0 0 0 o a o 0 0 0 0 0 0 0 o a o c= 0 0 0 0 o 1c 0 0 aooaoaaoc Qo-rES L COIJCLE-I -L 4000 L. r-E:l L r -occeo W ci H u s g iCOD. 3. 4" PIPE cAsr IQ PL1Lcc. 4. N -i0 t_01.piQC. 5. '(Y_t- GA-LLF-CH55 -i0 eE iU! T<&I ED I-r-VEL As - r�u 11.T DIMeN510N GHArd N0. A 6 ANO THAT IrHt. 9 f r,M WA9 it�1h1°�Gf .. Pf M>Q• �F:POIe$- 1 10.5" Co9.�" 2 23 � 1G A"- AM OPUN I b Or HaAt.TH ANTI TMf3 NZW ^fd3 +G 1`4°. q 20 " 1'i.5" , S 91.5 06 ' . 10 00' otj' I I 1- " 0,1' 12 Is q�•5� N�'ftsb: I. HOU515 4 WOI, LOGafILI 5 -(AKC%N MVM SIKVF-r-`( M<ePAKeO 6,1) 13UIJNe'( ASSOC,. LAS-T DAi0,17 MA`( V,,'.0110- 2. TMIh 1�7 TO G044 rlfy f fW'.. THG ltiWAGe, DI9PD9yAi. f{h7�hA WP:S�(ON9TR.v� ?CF9 Ag IN17I0ATZ47 FAN-" H1*1*7 ft .,A ANO THAT IrHt. 9 f r,M WA9 it�1h1°�Gf .. Pf M>Q• �F:POIe$- IT' WA-P 6W OV0 VltrreM WA'9' GOiat°JTi�tTCirew.it4 Af.G4 +. V° 'WITH ALA - TrAWPAlzO 1 Vtr ✓ A'f Ipt�9lJ1� THIS. A"- AM OPUN I b Or HaAt.TH ANTI TMf3 NZW ^fd3 +G 1`4°. d' 4F ;!,e 4Fz - eNT Or Hfr'ALT'}I . PrtoP. WP L- u t0 his il Sepieite Se N%mabw d Bede of which'a;o._att�W!,_,an;.,"c, ,ac Putn":06iinty DepartmAt Of-9ikth -Date Any ' pMton , cond ns: Jrorn, au;, q$aq OV4 .8 Pf .1 el of thij* sublocf. to if ' - ion. or .3/89 I �YN TR Orl ml 6 v , oik copies it issued by the R---.-,(P'WASTEW,AjT.E--R EFFLU,EN,,T,O C-6:L'ILE 'T 0 - -B,, tA'C" �PTIPTAL,COLIFQRW OUNTMF.Mr� ❑ FF OZEN DESSER,T °,P;L,ATEICOUNTI-,-"--,,,,..,' LABORATORY TECHNICIATI _PfA.100 M.-L., •C) f0TAL, CO L,UF0,RM COUNT-M; RER 1.00'M.L= Cj, FECAL COLIFOFkMfCOUNT,M. ❑ AGAR PLATE I?A 11-119 awkilgol all Al % K� "IDEPT DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH '767r�F,3jf Off ice Use Only is, '79—TREETAOURESS: WELL ,LO CATION TOWN17111MIC117' TAiGRIO M NUBER: 1)ellon Ad Pa. ffe_r__<6 A /S__ WELL OWNER NAME ADDRESS: lyle ld6 rs !12_a2rw:5ta �.0 PUBLIC USE OF WELL 1 primary.. secopdary, IYRESIDENTIAL ❑ PUBLIC SUPPLY 0 AIR1,CON.DdHEAT PUMP J__1 ABANDONED 0 BUSINESS Q FARM ❑ TEST / OBSERVATION BSERVATI ON I - 0 OTHER (specify) 0 INDUSTRIAL 0 INSTITUTIONAL' ❑ STAND-BY 0 ..AMqVNT OF USE YIELD SOUGHT. gpm.1N.O. PEOPLE SERVED EST4;017�DAILY USAGE d',1010 gal. REASON FOR NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION C ❑ REPLACE. EXISTING SUPPLY .0DEEPEN 8XISTING WELL - _. - ;OEPTH DATA WELL DEPTH ft. STATIC WATER LEVEL _Z ft.' DATE MEASURED DRILLING EQUIPMENT ' ROTARY YCOMPRESSED AIR PERCUSSION 11 DUG 0 WELCriOINT 0 CABLE PERCUSSION ❑ OTHER, (specify): WELL TYPE,.,..,! 0 -SCREENED. ❑ OPEN END CASING. VOPEN HOLE INSE.bk K El OTHER -j CASING DETAILS P , 0 j THEE LENGTH.BELOW GRADES ft JOINTS`:— ❑ W.F.-LIED IPITHREADED 0" DIAMETER in. SEAL: ❑ CEMENT GROUT eBENTONITE ❑ OTHER WEIGHT PER FOOT 7 lb.,/ft I DRIVE SHOE. 16YES ❑ NO UNER: ❑ YES V(NO ' DIAMETER (in) 'SLOT SIZE LENGTH (It) DE _Zj� TO SCREEN (11) 3f DEVELOPED? DETAIL FIRST 80S 0 NO 0 H lio S GRAVEL PACK I YES 0 NO GRAVEL SIZE. DIAMETER OF PACK in. TOP OEM —ft. 804M DEPTH — It. WELL YIELD TEST I If detailed pumping I METHOD- 0 PUMPED 1 tests were done is in- VCOMP�RESSED'A'IR formation attached? 0 BAILED O.OTHER sO YES ❑ -NO If more detailed formatio- descriptions sieve analyses WELL LOG are available, please attach. ons or eve an DEPTH FROM SURFACE i Water Bear- ing Weft Dia- "aier In FORMA.TION•OESCRIFTION CODE It WELL DEPTH It, DURATION hr. mirt; DRAW06 N:. W At, D YIELce.. 9prn, sufla ..Land 7 A 6 06Q 0 425:5o 25 Zz en��a;l' C//. ea V WATER CLEAR M 'TE QUALITY Q;CLOUOY HARDNESS Ej COLdR6 ANALYZED? 0 YES 0NO- ANALYSIS'iTTAdH_'E 6? b YES ONO --H STORAGE TANK: TYPE Aro CAPACITY GAL. PUMP INFORMATION 'C"ITY TYPE CAPACITY MAKER t- unWjr_4:!1_ DEPTH SOO MODEL 10 5- Y-6 46' VOLTAGGI,3L HP ELL DRILLER NAM DATE ALBERT M. �YATT f SONS, INC. ADDRESS.. Well Qr. . JJ 171A Rte. 311 R-R AP -12563 PATTERSON, NEX* rj 0 FROM LRURENT ENG RSSOC PC 4.18.1990 8 :49 P rmm CM?1Y DEPART OF IMLT71 DIVISION OF ENV7RMMML HEALTH SERVICES STp,WLej J- " RENC LAf-Np a:T Owner or Purchaser of Building Building Constzuctecl by Location - Street RATT6(,L"&C j Municipality SAW BoX `Z sToeY Building Type P. 1 is b. Z I section Mock Lot C091J aANX A'\066 CS�A�S Subdivision Name -0 34 Subdivision Lot # GUARAtmg OF SUBSURFACE SEWAGE DISPOSAL SXSM _.. I represent _that._x . am wholly_ and . completely responsible for.. the _location, _._ ana . worinship, 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 iamediately 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 Divi.siori of Bnvironirental Health Services of the Putnam County Department of Health as to whether or not the failure of the system to operate vas caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this l day of A pa,i I 3-9 10 C l ti General Contractor (Owner) - signature NoLkLe's Sit1d625 TNc. Corporation Name (if Corp.) wEsf o Id -PA2rK tzJ. Address t..{o pEwEI'1 a��_ N.Y. t2S 33 rev. 9/85 Wk Signature Title x , / � row% Y Corporation Name (if Corp ) I'- G_ FDIAr SITE L`ISrFCT =CV Date QD =ed t�v 1 OR SuEDITLESION Lam- � X� o� �/ � ✓7 rr, T;c_Jc =? `=_E^ n' -=� 2 CT i f E=--- `^ I -�-i'• _ EN;-C ICN Env crcc_* 1 y o7!(G /-F to A. 2L. �. C' CI_c C= `_ C'" cC" - =tah e 1/1' - 1/32 " / =CGL- I �{- _._ t� _ __ J'ra - 2(J' r— ICLr= a-iCia I �I ____ < 1-0 S. Rc= a 1c ei =cr E:- ^_sicr_, 50` SS Zr c 1C � =� as par 2L�r0tiE� I I 1G in t_ e ch 12" m; , LT=, a sac i c:l - Date cf PIEC -_rlt 11 pig 2 :1 harrie_y . IBC --H w 1� rE ��IG.Dt�I'a ! Size cf 1:-=, C- Z7avj=c -- soil nct striro� d_ S` :r_•e, try , etc- , cr: =ter t "tn 15' frc n SDS er`=-_ 3. Alarm, e_ 1GG ft- f_c: ware ccL_e /wa- �� ands _ Si:-51=7 DISFCEA L crc t I a. Eemt? c tan c_,-,- 5. Firs t hot c� =_ b_ SELL1c t✓.r_ i -_-- 1 - I C_ 1 CrL I aQ° hcr=r Cl — ^CLt within. 10 f=. cf dc° �c_C es *rat_ flaw c:-ar cv cle I a_ Ecu--e Ic =t=-- c`r acrrcvad plans. I I cf c X12! � 1CC =LE- as r —er crCr. ve- Plans 1 Lr i T;c_Jc =? `=_E^ n' -=� 2 CT i f E=--- `^ I -�-i'• _ EN;-C ICN Env crcc_* 1 y o7!(G /-F to A. 2L. �. C' CI_c C= `_ C'" cC" - =tah e 1/1' - 1/32 " / =CGL- I �{- _._ t� _ __ J'ra - 2(J' r— ICLr= a-iCia I �I ____ < 1-0 S. Rc= a 1c ei =cr E:- ^_sicr_, 50` 7 �G 1 3/4 1 TIl (a.!, I I 1G in t_ e ch 12" m; , LT=, a 11 pig ! Size cf 1:-=, 2- Cv Gr ---lc- t_ is I 3. Alarm, ole to crde 4. PM-0 easil"r ec= =___ =sib1= crap- a I I 5. Firs t hot c� =_ I I 6. Cvc1e Lv E_. _ n Dew te_ ^_t I I es *rat_ flaw c:-ar cv cle I a_ Ecu--e Ic =t=-- c`r acrrcvad plans. I I cf c X12! � 1CC =LE- as r —er crCr. ve- Plans 1 Lr i C. C==inC 18" ��-e crza^e_ I Gra _ =ce arc(a Ye11 acC= Cta^1e v CVi� h13FKLAf i a_ E✓Yes prcCer_�r c= ct���. b. C. A vices f w `z inside of hcc c. Esd:fi1? rr. =t - -a1 ccn�in=_ stones < a�� in cia�er_ I e_ C • irta i ri (a ? : t installed ed cccordinc to p1211 -� f. C;* ta?n Qra_ calf al L'rcte t= & _tC ECiSt_Svc'= �rC"L'ri2 C_ F--c tinc Cra- ns away f -ran SOS arc= h_ SL=face war =- crct= =°=icn ade --c-n=te I C= ..._C! C.:: V1C?- Cn Sicres Canter D - �' u)/ �to-fEs �. Co>v1ce.E`rE nova •�5.�.@ -r8 t�AY-s, r. >'EII.Jv:70 -CED Wr'H ki ° 3 score. 3. �" PE�FD I�TEC PIPE CASE I► I ?L&.CE. 4. Lab -,D i Q c--,. 5. -fist -G ALLe0e > 'ID C& IUt- fd,LLM UEVEL q" elf Gs�AVC� oe. C�.�'�44ED r NISNEO &I► APB r� 2. THIS Iy TO CIC42T1 THE bt,!;-11'0&,At. el-f�7T.1W WAS INDI0AT!✓17 ON THtf7 Pi.f r�T�M WAS cNeGY� GON�YR�GTF.ti.IN AGGOI? �"rANt7AFZ0 ?ZilLph � �: PLrrNAM OOVNTY 17t:,?Atz ANO TH>✓ NI✓1N. OP HEALA —H ��V N AS - 15U(LT THti S�WAG� 9NyTKVGT1W A9 AN12 THAT THr, r�,-f MC- orlPo4z>✓ ?. ,'f if E NM WAS NG>✓ WITH ALA, L'A-f 10N 9 0►✓ T E�,. ir,� OP H2AL.TH ', tlE�,PAIZTME�,NT nlMeNsIoNA�T , 23 I fO ' S X1.5' to q 0C, ' -70, 10 8o ` $3' 12 713 q1t. 51 ,. N OT>i5: ►. HOU55 � WO(.'I. 1,00ATtl s U KWEY ►°ieei°A Kf. t? *Y EAST VA15�rl MA`( 21 2. TH15 ly TO Gp..12TI" TH? DI°�POyAt- 5{STE:M WA-, INOI OAT C 7 ON _f H1`2 1't./ S f�YE�M WA5 tN SPt;GYF IT wAy GOVet� od�►z- GON�TizUGTti✓t7.lN AGGO� STANt�A}'Lt7 tZilL.E'h � k'-� E. PVTNAM Oal)1ITi Gi✓7Afz =L Ar40 THE NSW. 'Ia9 OP HeAL�TH . EX I SY vq S_ S IAKI-�N PROM O U N N ey ASSOO. 110. THG 5t WAGE ONyTKVGTI:t� A5 AN12 THAT 1-He, PTf M el DL' POFZIi C, �(yf EM WADI 'NGt�, NrrH Au, C,^-f N 5 oT- TH e 4r+rr OP HO -RUTH 5- OE�,eAFZTM5-NT lXy m v rF-o f'• Wt�%VV ey s`�� c unIAM COUIf!'><DEPA>rl Pl OF �ALTH - Didda d� Yr wWHw116S�edois.0 1.lIY 1�6U tshwWPrwlt./ _ •.w (�1IIIECAiB OF CO s1111rliwm x..st S111,41 at r � Tax .P ,/ med; o ..dA ■ast ri... Date ai FMbiu Approval Wefts Act ors 01,P rA2rn Te... � JcT ZIO l.�'.� batg Subdivision UVroved O�/5 'b �0 n Fee Enclosed Amct ;;,r %O O_', 0 sttMigg Tn, A2051.12CW T /1911" . W Aeeai / , 0 � � Fii�PCHDNod&*A=IsReqWmdWbimFMbomwlsftd sedbm Oaf Depm Valaee l�siK 1 HNet..a. Daalp, Flow G P D �p D . - Sowenge Sy Moss to a=M of !O 0O .caw s.pde r..t L - S 're 100'. eat 16j it E %% tG %/�i711 JV �— D Addiess w.w� sin Pave a+r.e wad... .. sue.. ,,.. _ on., i ;;, oo Swppb D4W !,r 0111« d 1 represent that.l am, wholly arid_eompNt ly responsible for ti Aesign ano location of 'the proposed - system(Q. 1) that tnr sa rate saw di sal system above described will be constructed os mown on_ttie.approvad as bit malttnera to and in accordance with the standards, rules a rpu ns o nam County. Oopertr!Nnt, of I"nN Const►uCtion.Complipnp' fetfgadory to the commissioner of MwKhwill tie saemi ted• to thw Oepsrt"C. and a' written 9uarantso' will`�N.'.furnisAiA ten "owner, his autoeef0►; hall, ass by ten 0uil ilf.that U4 WNW will pled. -in pod oWotinq condition any .olk of ,sail' as*rigs disposal systern- ,durlrg the Period of two (2), Years1mmedletalY fo110wHg thedatN of the iuu- Nice of the approval of the Cert(fkato of Construction Conlplis. oft ;origh"I system or any repairs ther to: 2) that the drilled wall described N6ove wiNl be.bc O o ehosrra on thcappregad.plen anA'that.fsidwall will M lost in accordance With ten ste rd u*a nd reputations of the Putnam kl County OipartmeNt o1'. Neai .. at. �: 84- /��J � �%�i: Sl.ri.d P.E. R.A. AddrNaI /G T Idnse NO APPROVED FOR CONSTRtJCTIONc This 8 ' 1 apir ies two;yeps from the!. daEo issued unless construction of the building .has been undertak and is Mlocable for cam" or maY be enlanded or modified when cos iidered.necitsarY - bj the Commissioner of Neeltll. Any charge or alteration of .construction Mulros. a '11'11 permit.' proved for ®Npotit of doir"k "'Altory saws er prwatd only. Rev. Date i� ^!'4�S / SY " Title 10/8$ e M 1 • 1• •t X91'• 1 IJ 0 • DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTFM FILE NO. Owner A)ECKLES Address DL17 Located at (Street) V,5-V0/y )2,94P Sec. l Block 6 Lot o� . ( indicate nearest cross street) > �) � Municipality tA- T7�S d N Watershed 907 e Iv / Date of Pre- Soaking �/D `� Date of Percolation Test b HOLE NUEM QACR TIME P KM =ON PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches �3 b 4% . i� a 4 5 1 x "G - /0!00 —L 2 /x:00 /. 3 /X01 - / `SD /, 4 5 1 2 3 4 5 '/Q �P 0 NUI'ES: 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 fran top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WrM APPLICATION DESCRIPTION OF SOILS E 4CDUMERM IN TEST EON'S DEPTH HOLE NO. HOLE NO. HOLE NO. G.L. 1' Or, 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12` 13' 14' 10101"Evionvii OR .01, INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENC7UUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used 40 Min /1" Drop: S.D. Usable Area Provided No. of Bedreams Septic Tank Capacity 0 gals. Type CG�� CT72I - C� - ",e 2�E Si Absorption Area Provided By of 0 L F. x 2.4 „ a} trench Other Nary Signature Address SEAL THIS SPACE FOR USE BY HEALTH DEPAR24FM ONLY: Soil Rate Approved sq.ft /gal. Checked by Date 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 p p �C> PCHD PERMIT #/2o/ O / WELL LOCATION Street dre(�/���{J D P�'�fJ. 1 own Village ity Tax Grid Number / l �JQ WELL OWNER Name Mailing k 1- LLS L 12N (L Address J-)4Pe-W6LL je_l GrPrivate 13 Public E OF WELL 1 - primary 2- secondary RESIDENTIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP 0 BUSINESS O FARM O TEST /OBSERVATION 0 INDUSTRIAL M INSTITUTIONAL O STAND -BY ❑ ABANDONED O OTHER (specify U AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED 9. 4 /EST. OF DAILY USAGE�al REASON FOR DRILLING 0,REPLACE EXISTING SUPPLY E NEW SUPPLY NEW DWELLING 13 TEST/ OBSERVATION 'D ADDITIONAL SUPPLY 13 DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED ODRIVEN ODUd GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES INO 15 LU(:A'M) IN A KISALTY 5U11ll1V151UN, 5UBU1V151UN: (' Lot No. WATER WELL CONTRACTOR: Name 7l) ');) C­ -�'���{T "D Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: OR- TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: 0Ue� LOCATION SKETCYON SOURCES OF CONTAMINATION PROVID SEPA.RATE SHEET - (date) signature PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted ander 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 De tment. r Date of Issue: 2 2r 19 �� Date of Exp' t' 19� e�rmit Tssu�ng ���icia Permit is Non - Transferrable Mite copy: H.D. File Yellow copy: Building Inspector 10/88 Pink Copy: Owner Orange copy: Well Driller Putn( aunty Department of FlealtY Division of Environmental Sanitation AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT. APPLICATION SUBMITTED- TO - PUTNAM COUNTY HEALTH DEPARTMENT ! , TO: Commissioner of Health - In the matter of application for` I, _ `,t�/>�N�^ _ �_, NEGkIeS — — — — — — — - — —.... represent that .I am an officer or employee of the corporation and am. authorized ' to acct- for.__NEGk�es — ViW"ef _5rje- - _— ____ =_ _ (name of corporation) `r having offices at _ jp� _4 _ biC) -�ic'�►'� g0 _ !- ICS', -1;5 Whose officers -are President �jVE" —� _ NEG���s 1 >O�' ��F _ 6L RN, Name ana Address). Vice - President TAMES _ - �1�z,lC�es ?0?( - — _ 4l - ir-►��- 1 '(Name and Address) Secretary _ _ « _ _ — (Name and Address) -- -- ^ ' Treasurer _ _________ __ _ __ .(Name and Address) + ' ' ' and that I =am-and will be individually responsible for-.any or all acts of the•corporation with respect to the approval requested and -all .sub sequeit acts relating thereto. Sworn' to before me this 9 day Signed _ �^ _ _ of 1988 Title 79-CS — — — --- — — — — — XZ Notary Puv_lic- AArdVII,) Iti Gt/. �,gzlkewf Corporate Seal ACKNOWLEDGMENT STATE OF NEW YORK ) COUNTY OF PUTNAM ) ss: 7Tv //JJ On this — day of C7U lJs' 1988 before me personally appeared RAND LPH W. LAURENT, the subscribing witness to the foregoing instrument, with whom I am personally acquainted, who, being -by me duly sworn, deposes and says that he maintains an office at 73 Fairfield Drive, Patterson, New York; that he knows WAYNE NECKLES to be the individual described in and who executed the foregoing instrument; that he, the sub- scribing witness was present and saw said WAYNE NECKLES execute the same, and that he, the subscribing witness, at the same time subscribed his name thereto as wit- ness. /gxw�- Notary Public DRINA G. WAPP Notary PubliC, State of New York No. 0146W'36 Qualified in Putnam County Commission Expires August 31, 19..: APP-rIIDL[ B PU NAM CCUNTY DEPA.RI,. OF HEALTH - DIVISICN OF EJVT_.ROMMU HEALTH SERVICES SuB.�I�ME: ('® / _9 �E & SUE SURFACv SAGE REVILV SEiEET - CONSTRUC'T'ION PMRMIT Sdg L ©T# j,-)E II��V e � �l DATE REU Cvc"'"D. : S /j J, l0• BY: MLC(- f�- (Street Location) JVEC•k'CES /l �E�S ��o (Naive of Owner) •' C. PI'S YES NO I I I I 1 I I Lam, ;=encz provides required 60 ft. max.. Para'-lei to contours l 100% exp. i MAY. 15LOPE SPS I i IX FILL SYSTR4-S clavbarrier I is i 10 ft. fill notes new spec. _ % RAICS OF FIZI I depth gauges )( X '100 vr. flood elev: I 200 ft. reservoir, etc. 150 ft. trigall /gall. DOCI�TS Pe_ -mit A olication Corporate Resolution Plans - Three sets s/s Engine - -s Authorization Design Data Sheet (DDS) SUED- LITISICN Deep Hole Log pe_rc Consistent Perc Results (3) Fill -- Pe_rc Hole Depth c3 House Plans - Two set letter Variance Realest C�v'RP.L Leal Subdivision Subdiwision A-cproval C`!e =:cam -ap prcval SSDS Aril. Lots C'iec:car Wetland (Tc�� /DEC Pe=t R & D) Data On DDS Plans & Permit- Same REC,U= DF'MI c CN PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volirce D or J P.ox;Tr_nch /Ga?lery; Prop pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes (grinder rate) Design Data: Perc and deep results Two-Foot Contours Existing & Proposed Driveiwa_v & Slopes Cut Footer nc/Gstter,Cur --in Drains (discharge OK) Per.-- & Deep Holes Located Representative of pri na-.ry and ex- -ansicn Expansion Area;shcw--n;gravity flow,suff.. size If Purred Pit & D Box Shown & Detailed House - No. of Bedroans Wells & SSDS's w /in 200 ft. of Proposed System Properrty Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 45° w /clea-nout SE RMA" SON DISTANC_S SPECS IED CN PI ANN Fields 10' to P.L. , Driveway, Large Trams jop of L 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. e%-par 15' to Drains - Curtain, Leader, Footing 351to catch basin,stormdrain,pip d watercour_= 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' fran Foundation; 50' to well 15' Well to PL 9 ��..o0 1W PI / I49000AL,• S6P'TtG �o TANK _I a 3 . ENC l Mau. s J / P> zi/ V YixP NSION A / iYP S /