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1 L��OIi. - TAfT TTTATT
WELL CONFLE110N Kzrvn1
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
�6V tiI� PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: TOWNIVILLACLICHY TAX GRIO NUMBER:
�ri!�►.lils5 y �,
WELL OWNERo
NAME: ADDRESS:
ohs
PBIVATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
MIRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. 1N0. PEOPLE SERVED / EST. OF DAILY USAGE.3100 gal.
REASON FOR
DRILLING
[] LACE EXISTING SUPPLY [TEST/OBSERVATION ❑ADDITIONAL SUPPLY
Lam 4E . SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL
DEPTH DATA
�
WELL DEPTH ® ft.
j��
STATIC WATER LEVEL SL_ ft:
DATE MEASURED. 1 y
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION O DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑OTHER (specify):
WELL TYPE
O SCREENED O OPEN END CASING E2 OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH 2 ft.
MATERIALS: STEEL O LASTIC O OTHER
CASING
DETAILS
LENGTH BELOW GRADE _____ � ft.
JOINTS: O WELDED THREADED O OTHER
DIAMETER in.
SEAL: EMENT ROUT ❑ BENTONITE OOTHER
WEIGHT
PER FOOT —2 _ Ib. /ft.
DRIVE SHOE ES ❑ NO I LINER: O YES ❑ NO
SCREEN
DETAILS
DIAMETER (in)
"SLOT SIZE
LENGTH (ft)
DEPTH TO (ft)
DEVELOPED?
FIRST
O YES. O
HOURS
SECOND
GRAVEL PACK
° Y
NO
GRAVEL
SIZE:
METER
OF PACK in.
TOP
DEPTH ft
8 OAt
PTH It.
WELL YIELD TEST It detailed pumping
M9H00: ° PUMPED i tests were done is in-
COMPRESSED AIR ,formation attached?
O BAILED ❑OTHER ; ❑YES ❑ ' NO
1PIELL LOG it more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
I water
Bear-
i ^9
Well
Dia
meter
In
FORMATION DESCRIPTION
coot
tt
tt
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft,
YIELD
gpm.
Land
S.rlas,
7
A10
934(
�0
83
oG K�
9(�
7 u
2
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES ❑ NO
v
STORAGE TANK: TYPE W A �SO wel x tee
x " 3a L � • �
WELL DRILLER NAME lGl�Sa v 0 S DATE
ADDRESS �j �` �j! r11 /v �'Je SfGhMRE
1
PUMP INFORMATION INF�OR�MATION .
TYPE CAPACITY I
MAKER DEPTH 74D .
MODEL -719 2 DZi/ Z VOLTAGE D� HP zq—
3/89 f
Bn �
Yorktown Medical Laboratory, Inc.
321 Kear Street .
Yorktown Heights, N. Y. 10599
(914) 245 -2800
Director: Albert H. Padovani M. T. (ASCP)
O C-8 &�✓y �n�T .
�r'/jo ''���:
L
J
LAB y:7. �:;��a41'
Date Taken: Time : o k°';1,,
Date Rc'd: 0 2-v Time: ��J
Date Reported: - 990
Collected By: 7V, CA_-
PO/Client #
Referred By:
Sampling Site:. cjb# �
Phone (�?)
REPORT ON THE QUALITY OF WATER
INORGANIC L) MICROBIOLOGICAL NFU71 OOML
Alkalinity
< = Less Than
Chloride
> = Greater Than
Y Copper
Not Applicable
Detergents,
MBAS
Hardness,
Calcium
Hardness,
Total
,-on
Lead.
Manganese
Mercury
Nitro gen,,.Ati
I
.Nit�.oge.n,
Nitrate
AT.itrogen,
Nitrite
` Phosphate,
Total
Silver
_
Sodium
Sulfate
Sulfide
Sulfite
Zinc
PHYSICAL/MISCELL&NEOUS
_ Standard Plate Count
(CFU/1 mL)
Membrane Filtration Method
4
Total Coliform
--- --- -- Fecal Coliform
_ Fecal. S 'lleptococcus
pH (S.U.)
Color (Units)
Conductance (uhms /c)
Odor (TON)
Turbidity (NTU)
Most Probable Number Method
Total Coliform
Fecal Colifo=
Fecal Streptococcus
Presence /Absense (PA)
Total Coliform, P A
KEY FOR TERMINOLOGY
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 ab Use
(For Lab Use)
SAMPLE TYPE:
(Check One)
V"Potable
Non- potable
.OUTGOING:
(Check Each)
s
HNO
HCl"
_-� TT
ZnOAc
Na2S203
_ Other:
INCOMING:
(Check Each)
LE
40C
SGT
4 /1E 2000
GT
200C
_
,pHLE2
pH
GE 12
Other:
THESE RESULTS INDICATE THAT THE WATER SAMPLE ) (WAS NOT) (NA) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH WASYORK STATE PUBLIC DRINKING
WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE CO LECTION.
THESE RESULTS INDICA THAT THE WATER SAMPLE (DID) (DID NOT) (NA MEET THE
SATISFACTORY CH QUALITY STANDARDS OF THE NEW YORK STATE C DRINK -"
ING.WATER CODE , FO THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION.
/x 7/87(Rvsd1 /Q,O)RWE
e%,or+��aAnvani - _T_ AS P _ Director
� -`� -.
n
APPENDIX I.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIROWENTAL HEALTH SERVICES
MR. & MRS. J. PASQUALE
Owner or Purchaser of Building
JOHN DE.PASQUALE
Building,Constructed by
Location - Street
PATTERSON
Municipality
2 STORIES COL.
Building Type;
1 4-
Section Block Lot
2149
Tax Map Number
OVERLOOK WOODS
Subdivision Name
4
gad- vision Lot #
GUARANI OF SUBSURFACE SEWAGE 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 Divisioci 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 t �'� day of IkNPFj6 19__ Signature
Title
GtWal Contractor (Own ) - Signature
Corporation Name (if Corp.) 1
103 SUCCABONE RD. BEDFORD HILLS
Address
MORON
Corporation Name (if Corp.)
MOHEGAN LAKE
Address
rev. 9/85 16
mk
0
.J
FINAL -SITE INSPECTION Date 7 �0
STREET L T_MN ^ MC'
A/
�VU,S / CWNF-R U/JLEy - —
PERMIT i 6"— 9I 4 OR SUBDIVISICN LOT 4 ';Z — % --
II.
S
IV.
V.
VI.
YFd-
No
CAF' • S
SEXAGE DISPOSAL AREA
a. SDS area located as per approved, plans
I
b. Fill section - Date of place-Tent
2:1 barrier. LGTH W-MTH AVG.DPTH
AAA
I
c.. Natural soil not stripes
I LZI.
1
d. Stone, brush, etc., greater than 15' fran SDS area.
I-
e_ 100 ft. fran water course /wetlands.
I
ILA
g/
.SF,-V-'-GE DISPOSAL SYSTEM
a. Septic tank size - 1,000 —1,250.,
b. Seotic tank installed level
(
I
I
c. 10' minunn fran foundation
I
I
I
d. No 900 he_nds, clea.nout within 10 ft. of 45° be--,.d-
e. DISTRIBUTION MX
1. All ouLeTs . at same elevation - water tested
2. Protected bzlcw frost
3. MiniunLT-n 2 ft. original soil bet:aee -p box and trenches
I
I
I
f. JL"NCTION BOX - properly seT
I / A
I -
g. TRENMES
1. Leng -Ltri r=.r..'ui red instated g7
2. Distance to wctercourse n—easLLed
3. Installed according to plan
4. Distance center to center
5. Sloce of trench accentable 1/16 - 1/32 "/-:=cot.
I
6. 10 feet fran rocerty line - 20 feet - fcundaticns
{
{
7. Deoth of tench < 30 inches fran surface
I
I
8. Roan allcwei for e ca.nsion, .5w
9. Size of gravel 3/4 - 11" diameter
(
{
10. Depth of caravel, in trench 12" minimum
I
I
L. Pire eunds aapnei
h. PT, OR DOSE SYSTEMS
1. Size of pump chamber
I
2. OverrC icw tank
I
3. Ala=, vis -uml /audio
4. Pump easily accessible manhole to grade
5. First box baffled {
6. Cycle witnesses by Health Deparbnent
estimated flaw perr cycle {
,
a.. House located per approved plans.
b. Number of bedrooms
.WELL I
a. Well located as per approved plans
b. Distance fran SDS area measured 100 ft. {
C. Casing 18" above grade.
d. Surface drainacae around well acceptable.
OVERALL jiuORKM�THIP
a. Boxes 2rouerly grouted
b. All pipes 2�ally backfilled I
c. All pi22s flush with inside of box
I
d. Backfill, material contains stones < 4" in diameter
e. Curtain drain installed according to plan
AIM
I
f. Curtain drain cutfall protected & dir.to eYist.watercourse
g. Footing drains discharge away fran SDS area I
i
h. Surface water- e- adequate
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER.WELL
PCHD PERMIT
FWELL CATION
Street Address
MCMANUS RD.
Town Village City Tax Grid Number
TOWN OF PATTERSON SECTION -1 LOT 4
NER
Nam e
JOHN DEPASQUALE
Mailing Address
103 SUCCABONE RD., BEDFORD HILLS, NEV YORK
MPrivate
O Public
USE OF WELL
1 - primary
2 - secondary
m RESIDENTIAL
O BUSINESS
O INDUSTRIAL
O,PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O,FARM O TEST /OBSERVATION
[]INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify,
AMOUNT OF USE
YIELD SOUGHT
�a gpm /4� PEOPLE SERVED 4 /EST: OF DAILY USAGE $4o gal
REASON FOR
DRILLING
MNEW SUPPLY OPROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION .
OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
^�L,� -i �•a�ow�ls\.�l�.tvG" ,
WELL TYPE
XDDRILLED
DRIVEN
E]DUG
®GRAVEL
aOTHER
IS,WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No. 4�
WATER WELL CONTRACTOR: Name NORRIS 3 STONE & SONS Address: SOUTH SALEK. N.Y.
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: N/A TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: GREATER 1HAN5,000'
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF-THIS APPLICATION RA SHE
04t e) 17 ig a •� ,
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.
Date of Issue:
Date of Expiration: �r 19� - Permit Issuing Official
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner M
llr�v,�e� i.rre s. T.7-1 1
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D. /
Deputy Cannissioner of Health - FIELD ACTIVITY REPORT - Sheet / of
n TMCMYvPTr%AT
NAME — Orig, Routine
_ Orig. Camplain
ADDRESS C� Aa�&�� Orig. Request
No. Street Tom qM No. _ Compliance
_ Canplaint Caup
MAILING ADDRESS Final
P.O. Box Post Office Zip Code Group Illness
Construction
TELEPHONE
Reinspection
PERSON IN CHARGE Field, Sampling Only
OR INTERVIEWED Field Conference
Name and Title
Other
DATE
TYPE FACILITY
TIME ARRIVED 3 j 1 L TIME LEFT 3'357
FINDINGS: n _L fl 11 n n
Explain
INSPECTOR: yyLa/vuqlle� TELEPHONE:
,.Signature and Title
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE°
6/86 TITLE:
A ' APP II= B
PUI'NA-H CCLRNr`! DE2ARTA5-W OF HEALTH - DIVISICN OF ENV- MCNLMR -aL BEA ? SE:-RT710ES
Lam? 71 -IDUPL KATER SUPPLY & SU Sv FACE alv7 ! , DI-cPr SZ-L SYSTEMS
RE•J? �Ty- S'n� :TI' - CCNSTR=ICN PEP=
II -
CaV-VFvrs I -s
( NO
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r fl
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1,4
DATE R:.`T == vr�
BY:
DCC TM S
P °__ -ait Amzl ic- ticn
Co =rat-- Resoluticn
Plans - Three sets _
Esc? n�rs autzGr_Z t_cn
Design Data Sine =t (DCS)
Ceep Hole L."C
Ccnsist`rlt. Perc
Perc Hole PEoLn
�/
SUED � �,r_S -c
(3' ill
c
Ecuse Plans - T tiC sc L7G�e1 xX/ �vC YX1
Variance :chest -4
Lecal Sucd_vi=ici, Sufic CUa "slat
S: c,--iVi Sicn P -c_ -val C.er:c&:�
;tie 'and (TC'wn7 /DEC P °_='tit R & D
Data C1 DCS Plans & P °_'_�:�i - .
S=-,Yage Sv=tyl Plan - (-cr_-i a-r_zw)
_c . P_C-Fil= F
- -11. Profile_ & D_T.crs_Cn5 - VCi'
D c'r J Ec:{ ; T. an /C- _! e r� ; ^ —,
Sc^L C Ta.Rk - S----=- , Pe. 11
S- arvice Line 1= C4c=
_rstructicn Notes � r tic =r ratell
Design rat`: perc and -deco rasa: _s
Two -Foot Contours ax-i st,i nC & P- -Czcs. ,,;
Dri,.ewav & Sloces Cut
F otin�Gctter,C Our Drain=
Perc & DEec Holes LL^catea
(c_scnarge CE
Represar tative of priir•,=J ar-d exceansica
_EKpansial Prea;s~cw-LI;gravity f1c ,ssf =. siZ:
If F.med Pit & D Box Shcw-n & De —=ilw
'of Eeircans S
Wells & SSDS's w /_n 200 ff. cf r occEed SYs"
P_cce_rty metes & EGumcs
House Sethac{ Necessary (' iq:L-,at lot)
House Setter - 1/1-1"/ft. 4"0; y`rJPe Dire
No Bends; Max. E,--n s 450 w /cl =_.out
SEPaRP.TICN DIST. \�.S SPECIF= C-i Pray
Fields
10' to P _ L . , Drive:eav, Large Tr aes , Tc_o of
20' to Fcuncaticn Walls
100' to Well; 200' in D.L.O.D, 150' pi
100' tO .S`..Z".i, ;VcC - 'C_arse, lake Unc. a
15' to Drains-3ar tr '_Z, Leader, Fco t-ing
35'to =-toil b-=siII,sL-orii=ai- ?l,niceo waters'
10' to ;eater Line (pit—S-20')
50' inte_*_iuttent dr ain�aCe cc
Sent; c Tanks
10' fran Found. Lion; 50' t•c we-11
15' Well to PL 9
PUn M COUNTY DEPAFaMENP OF HEALTH
DIVISION CF ENVIRONMENTAL HEALTH SERVICES
J
DESIGN.DATA SHEET- SUB.SUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Cwn r MR. JOHN DEPASQUALE dress 103 SUCCABONE RD. BEDFORD, N.Y.
Located at (Street) MCMANUS ROAD Sec. 1 Block Lot 4
(indicate nearest cross street)
Municipality TOWN OF PATTERSON Watershed
Date of Pre - Soaking =-
"zl Date of Percolation Test
JULY 1, 1988
3.3
HOLE
8.3
NUMBER C1= TIME
PERCOLATION
PERCOLATION
• Run Elapse
Depth to Water From
Water Level
8.3
• No. Time
Ground Surface
In Inches
Soil Rate
Start -Stop Min.
Start Stop
Drop In
Min /In Drop
Inches Inches
Inches
0
A 1 10:56 -11:19 -23mins 18 2.1 3 7.7
2 11:19 -11:44 25mins
3.3
3 11:44 - 12:09 25mins,
8.3
12:09 - '12:36 27mins
4
9.0
4 12:39 -1:04 25mins
8.3
5 12:36 -1:03 27mins 18 21 3 9.0
! 1 1102 -11:52 20mins
6.7
2 11:52 -12:14 22mins
7.'3
3 12:14 =12:39 25mins
8.3
4 12:39 -1:04 25mins
8.3
5 1:04 -1.29 25mins 18 21 3 8.3
2
3
4 -
5
NOTES: 1. Ttsts 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
14'
INDICATE LEEM AT WHICH GIOUNDWATER IS ENCOUNTERED NO GUM WATER UMMEPM
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENOOUNTERED
DEEP HOLE C>BSERVATIONS MADE BY: CHAS. H. SELLS, INC. (WAB) DATE: JULY 1, 1988
DESIGN
Soil Rate Used E3.i y Min/1" Drop: S.D. Usable Area Provided
r,-r
s
No. of Bedr Septic Tank Capacity gals. Type /,akAc,.
Absorption Area Provided _y L.F. x 24" width trench
Cutler
Name . CHAS. H. SELLS, INC. ,
AddressP.O. BOX 426, 550 NO. BEDFORD RD., ,
f ti •> t
BEDFORD HILLS, NEW YORK 10507s�tisF No.
p�OFFISI `�t3•F�
THIS SPACE FOR USE BY HEALTH DEPARTNIENI' ONLY:
Soil Rate Approved sq,ft,/gal. Checked by Date
., .,
TEST PIT DATA REQUIRED TO BE SUMMED WITH APPLICATION ,' .
DESCRIPTION OF SOILS ENC OUNrERED IN TEST HOLES
DEPTH'
HOLE NO. 1
HOLE N0. 2 HOLE NO. .
Mature Woods
Hues D. Br. Sandy .
G.L.
Humus..
M
1'
D. BR. Ty ?SOIL
2'
L.-BR. SANDY LOAM
:L.BR. SAND & SILT
W /SOME COBBLE
OLIVE BR. SANDY
3'
LOAM W/ SILT
4
�
MEDIUM TO SMALL -
-'
51
TIGHTLY COMPACT
TRACES OF CLAY
SAND & SILT "'.
BOTT. OF PIT
6'
NO WATER
71
BB LL
DR Y VO�TESOF�PIT.
8°
9'
10'
11'
'
12'
13'
14'
INDICATE LEEM AT WHICH GIOUNDWATER IS ENCOUNTERED NO GUM WATER UMMEPM
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENOOUNTERED
DEEP HOLE C>BSERVATIONS MADE BY: CHAS. H. SELLS, INC. (WAB) DATE: JULY 1, 1988
DESIGN
Soil Rate Used E3.i y Min/1" Drop: S.D. Usable Area Provided
r,-r
s
No. of Bedr Septic Tank Capacity gals. Type /,akAc,.
Absorption Area Provided _y L.F. x 24" width trench
Cutler
Name . CHAS. H. SELLS, INC. ,
AddressP.O. BOX 426, 550 NO. BEDFORD RD., ,
f ti •> t
BEDFORD HILLS, NEW YORK 10507s�tisF No.
p�OFFISI `�t3•F�
THIS SPACE FOR USE BY HEALTH DEPARTNIENI' ONLY:
Soil Rate Approved sq,ft,/gal. Checked by Date
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4 SD $ 83:1
Design f /ow:
.: 5 Qc ,2� lOZ'O' . `
V r . Septic Ironk
ti
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� 6 o q2 3
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