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TWO NTY
DEPARTMENT OF HEALTH
Division of Environmental Health Services
CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL dd
PCHD PERMIT # 111 1V_9D
WELL LOCATION
Street Address
Town/Village/City Tax Grid Number
/4L <f
WELL OWNER
Name Mailing Address - R RrrE5
C, 14P_L) E YFL b') 0 0
Wrivate
0Public
USE OF WELL
1 - primary
2- secondary
O RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0 PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP
O FARM 0 TEST /OBSERVATION
0 INSTITUTIONAL 0 STAND -BY
0 ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
,J gpm /# PEOPLE SERVED S /EST. OF DAILY USAGE 6-0 al
REASON FOR
DRILLING
0NEW SUPPLY []PROVIDE ADDITIONAL SUPPLY 0TEST OBSERVATION
gREPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
PLf4Cz57
Co /q ?';,5-nj 7- te)EI -L
WELL TYPE
DRILLED
DRIVEN
DDUG
a
GRAVEL
E]
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: Nam �--
�DC�t� /-��P.TFoS /A /U IitIE_LLC'O • •=i�lC . Address., /CJ.S' /'Z.
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: `YES Vto
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION WON SEP
(da e) (si
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 ZDDerLtment.
1Date of Issue: 9
ti ' Permit
Issuing Official
Date of Expi on : 19
Permit is Non - Transferrable Mite copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
I
Boyd Artesian I
R. D. No. 5
Carmel, N
(914) 22
ABILITY
eel S�
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c\O
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of
.� INSPECTION
NAME I `r_. - yam., W / � Z -1- - 1,1
ADDRESS /� 711- // 1011
No. Street Town 'TM No.
MAILING ADDRESS 4
P.O. Box Post Office Zip Code
TELEPHONE
4 D11 W-0-9, '!i
• • p• DID
Name and Title
DATE / TYPE FACILITY C .•C-/
TIME TIME LEFT
FINDINGS:
- f /2 �/���51
INSPECTOR:
s ' .�I'•.%'> ''"..�' .� '7'Ci /,. -.�r Cam.✓ i• ` �'1
Signature
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
Orig. Routine
Orig. Complain
Orig. Request
Canpl iance
Canplaint Cane
Final
Group Illness
Construction
Reinspection
Field, Sampling Only
Field Conference
Other
TELEPHONE:
Explain
I
tl
3
weer or Purchasep ol' Building
Building Constructed by
Location - Street
Building Type
0
d}.
Municipality
Section
Block
Lot
GUARANTY OF SEPARATE SEWAGE SYSTE14
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 guaranty to the owner, his succes-
sors, 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 initial use of the sewage disposal
system, or any repairs :Wade by me to such system, except where the failure
to operate properly is caused by the willful or negligent. act of the oceu-
pant.of the building utilizing the system.
The undersigned further agrees to accept as conclusive the de-
termination of the Director of the Division of Eivirorirriental Health Ser-
vices 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 L��/ 191 Signature `�'
Title
If corporation, give name.
and address)
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.
Division of Envircnmental Health Services, Putnam-County Department of Health
{ e PiJTNA"M COUNTY DE^ +i' r+ZENT- OF HEALTH
DiVisfon of Enliir-onmenial: Health 2
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM
Town or illage
Located at, I " Tax Map jZ– Block '2
Subdivision . 1 wns1 Lot Job
owner ''�,c= rC � Address T �G
C�l�1Mi�iA�
Bu�Id�ng,Type Lot Area ' N,
Number, of Bedrooms Desi n ;Flow. . GkL
g 7`� M` Total Habitable Space. Square Feet
h' r '
p
Separate Sewerage =System•to consist of /�� .Gal Septic Tank' and D,n1E 8X 8, 6E
:'�'T/�IfJtr Add ►ess
+.To be :constructed by _ • ' ,• ,. ,` -
Water Supply Pyblic Supply. From
Pnvate Supply to, be. drilled by.'
J Address . "
�.._.
Other Requirements
I represent that.l am wholly and completely responsible f'o'r the design and location of the proposed sy m
stes) .1) that the separate sewage' disposal system
atiove.`described will be construcfed;as•shoviln on the approved amendment there to and"n accordance .with the standards; rules an regulations o e Putnam
County Department of
Heatfh; .and that on,completionthereof a "Certificate of Construction Compliance, satisfactory. to-the Commissioner'of Healthwill
'tie submitted to .the De` .:
partment; and a :written °guarantee will be .furnished the owner his successors, heirs 'or assigns by the builder, that said builder will
,place in good, operating, conditionk.any ,part'.of _ said •sewage disposal system`, dunng the: period of, two (2) .years immediately 'following thedate of the issu-
a°nce of the approval -of, the Certificate-of Construction, Compliance 'of, the ori_gg system'or any „repairs thereto; 2),that,the drilled well described above
_ u
will be'located as shown on the approved plan and that said well wiil.be installed . cordance with , e, start aids, rules., and_'regu aa— f�'ons of the Putnam
„County Department of ,Flealth.
c
hut.%' 1q IG'I!o ,
Signed P.E R.A.
Y
Address License No,
APPROVED FOR CONSTRUCTION.: This approv expires one year” om.t dat issued -' n` uction' of the _budding has been undertaken and is
revocable`for'cause or.m y,be'_amended or modi ' "whenconsidere neces ry: b o fission Heelth: Any change r ion -of construction
reGuves:a' new,perm�t Approveq ',for- of, domestic sanitary se a nd /or' te' r; supply only.-
...
Date
i Tale
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner je. .L �p Address V_Cu;r i(A
Located at (Street Sec. iZ Block Z Lot
6dicate neares cross street)
(c
Municipality. pATieetL'*ti Watershed \r;/ W
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Elapse Depth to a er a er ve
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
1 l 4s 1'�l(o I 2(0 2-1
2
3 041 - i:149 Z 2 2'1 a" z
4
5 V-54 _ i ,-53 Z a4, Zi i 2
1
2
3
4
5
2
3
5
Notes: 1) Tuts 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.
,- I
TEST PIT DATA REQUIRED TO BEUBMITTED WITH APPLICATION. -
DESCRIPTION OF SOILS tdCONTERED IN TEST HOLES
DEPTH HOLE N0. ! HOLE NO.
G. L.
611
12►►
18►►
2411
30 ►►
36►►
`F2►'
48►►
5411
6011
66►►
7211
78"
8411
HOLE NO.
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY -� V_ Date /WW� ij jq-16
DESIGN
Soil Rate Used O -S Min/1►►Drop: S.D. Usable Area Provided
No. of Bedrooms o Septic Tank Capacity 9uQGals.
Absorption Area Provided By L.F.x24 �-
Type 5
width trench.
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked ny:;.,�'� Date
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