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631- 589 -8100
23. -1 -71
BOX 7
11.11
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11.11
awmhe rot A. 0, Fr 7( 4 _
Number of Bete�e DWV Flow G P D"L-
SeMnte Sowa w S7e1` is "Now et 'Gam Sardt Twit ud�
To M:ae>rQd 6F T B
Wdur.Se*!4: Pu k Sept
&b*4 described will be constructed as, shown on the SP
County Department of Maaltl% and that on complet
be submitted, to the Oeptirtnwit. and a written .pus
�1eco in good. opetating eorid0lon any part of said
Once of the 4pprowl of the Certificate. of Construe
wiil be located as fhow on the approved Plan and that
County Department of Health.
Fm tecden Ono j 1111010121 Vabo
PCHD Nodbodea b Reaetsed wbm F)0 b eenotated
will be furnished the,owhe►, his sucCassers, heirs or assigtls by the buitde►, that 11
t disposal system during the period of two (2) yaara immediately following thud
*mMRaM of the original system or any repairs thereto; 2) that the drilled welts
NI ill M In Ntl Axor%ancemok tlandarAS, rules,antl rqu na of
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of, to
revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. An
resluhes a M permit. pprgre for tli fat of domestic sanitary M n /a ate water supply only.
v.j,�10/88 Data y
a building has been undertaken and is
V change or alteration of construction
Title `—�"�
_j
0
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
—(�' �/ —,Y(
PCHD PERMIT #
WELL LOCATION
,,/6treet Ad&
fla.rm
DWI
UZL�n
I Tax Grid
3.
Number
WELL OWNER
ame ,
Mai , ing dr ss
' M �C c�
Private
Public
USE OF WELL
0- primary
2- secondary
RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
O AIR /COND /HEAT PUMP O ABANDONED
O TEST /OBSERVATION 0 OTHER (specify
O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT J�''' gpm/ # PEOPLE SERVED /-6 /EST. OF DAILY USAGE 125? gal
REPLACE EXISTING SUPPLY O TEST/ OBSERVATION GIADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING1 0 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
,
WELL TYPE
DRILLED
13DRIVEN
[3DUG GRAVEL.
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES /` NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: #At
Lot No.
WATER WELL CONTRACTOR: Name 7712D, Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES /I8 )�'NO
NAME OF PUBLIC WATER SUPPLY: /U/ TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: � � 2
LOCATION SKETC & S ATION PROVIDED
SEPARATE SHEET
(date) e)
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 such a miner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 2 19 % _
zw-
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
•' • P •' • I 2,N, ma manill.1 : 2111• M:?►
DESIGN DATA SHEM%- SUBSUFACE SAGE• DISPOSAL SYSTEM % FILE NO. '
C<rJTle •� � 11c dia� i�� i b� P fT` Address �I� ~T� 4✓ L � � ��ed/'� d-
16cated
at (S.treet) /A'l&A laVC
_._. � Sec. �t 3 Block I Lot '71
(indicate nearest cross streetY
SOIL PERCOLATION -•TEST DATA RDQU= TO BE.SU&'r= rs= APPLICATIONS
Date of Pre - Soaking •-,S .•C Date of Percolation Test
.Hol&
amm
-
CLOCK TIME
A
FERCOLATIt3N PERCOLATION
Run Elapse
NO. Turn
Start Stop Min:
Depth to Water kYcm Water Level
Ground Surface In Inches -Soil. Rate ..
Start Slop Drop In Min/In Drop
Inches Inches Inches
.5
1
'
2
3 _
4
NO'M: _,..1., . - Tests: to,be repeated, at: same depth until approximately equal. soil rates..
are obtained at each percolation test hole.:. A1.1. data to' be: suimitUd
for review.
2.5 Depth measurements'
.. to:. be madam - £ran top of hole. _
G. L.
1'
2'
TEST PIT DATA REQUIRED TO BE SUM= WITH APPLICATION
DEscRIPTION OF SOILS ENX=NrERED IN TEST. HOLES
HOLE NO. , ' SOLE NO. HALE NO.
I3`
14'
INDICATE LEVEL AT WHICH GROUNUATER IS ENQOUNTE RED
INDICATE LEVEL TO. WHICH WATER LEVEL RISES AFTER BEING F.NUOUNMM
.DEEP HOLE OBSERVATIONS MADE BY: DATE:
DESIGN
Soil Rate Used Min/I" Drop: S.D. Usable Area Provided.
No. of Bedroams Septic Tank Capacity gals. Type
Absorption Area-Provided By L.F. x 24" width trench
Other
w ,..
nme r sue,; p� siana ,►.�
. , _ - -
Address y / • /�l Q , SAL
THIS" SPACE FOR USE BY HEALTH DEPARIMENB ONLY:
Soil Rate Approved sq.fi:;e 4 . `.' Checked by ' . ' :'a., -.' J • • . Date
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