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HomeMy WebLinkAbout2614DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -3 -4 BOX 22 Wd 'p,- .. 1�6 MR r�� ; lJL 02614 . .. . x x - � r� s e -k t�!/�' V �. ro • vy "� . ti. i ?� w £4s3 2 x .a '� ;, � � .,� p rz s .11­ _ ra � 1\!. t/ r r r & � ` � , 'Mv` - -- ,- „7-,r• 'S, „t,6� .a, --Eµ •F,4> ,� t�„ -�'` $r• a �� y, �' ~ _ '� - =�` n �br c _} %�* t p ,� z F e s a a x r , � s W q . PUTNAM COUNTVY4 DEPARTMENT ' OF HEALTH = f - 4��,lsaFS33n of�F�drronmcnt, -, _ ltlr Servrces, Carme% p'V _ Y i0S�f2 ” y , s CERTI,FI,CATE_ =0 _, -,• - MP:LIANCE,,FOk'iiS, WAGE_DISPOSAL SYSTEM ' ©WZ Pu�n�m Valhl � 8 S 8 �► C �, ,11 Town or Village b ®twe�n Pu g Pe�k�ki1�1 Fi011ow R ©mod k 19r k_ 1 r Located at ` �, ' � `z� Section Block b 4 {. P X Owner '� r x % e � " Lo �9Z'C!9 �.9 b3OgJ 515 -11 t - �Gleririt Nef3e &R�1l PT6J.�ffi x "� s Y �r�" yJ Separate Sewerage" "System bu=It by , gddress e { Consisting of Gal Septic Tank , Inea eetX h 4'.> width trench = ► ` � If `:- �' :: 6 seep ge tp ,t 5 f � 6 dm�p ° by e wid® t Other requmements a £ � s f °+ -"r - • -. 4- `x,+* -%4 "• Fi"+ ^'1 "'� t *,s 3 z.a4 ,P,^ {2 F• x eA 3 f # r'i y. v, f, `, Water SuP.'ply�PUbl�c SuPPIYFrom s fi 11 ` , $ kPrrvate Supply �r f1�'�ri �u— r b �.1� 1iir �l.�i ®� $ 5 % gg r - 1 y 11 �p�r r Address �R• �i �. Put,i��m�Zl il`]��e�r • Di v• Y♦ 1 ©779 a f x ' ; a Y . w„ x � t +..'mod i, t x s rog , g& 54, 7= 6 _,.�+ 4 u t9' � .,F -. y f �, S � 3c•G --5 3 ,.,� y4.11 �, � 3 j Building Type Split LBStml� Noi Hof Bedrooms Date Permit Issued °4:T - k : ; ,-`+ , -- r a fix, ,� u &a f S s'kS„�. z 2z 'r ,r Y�'c t':` t'° nr �„ .fit a`'✓ ? -E, � .a Has =Erosion Control Been - Completed n� - �` #` ��a� '� 11 ,� R "�, 9 u " -Viz' .==sib ``` P., at5 -n ' S'�* xs- a z TM, ¢ q ww 7 , m r .. F i_ certify ,that the systems) as listedservng; the, above prem;�ses,wece constructed essentiaily�a "s hown o "n >the -plans of the <;com ed work "(copiesTof wnich'•are ,'attached);';and n -accordance with; the standards ,.rules and; regulations plans filed 'and the permit .issued,, y -.;the P.,'utn County Departme'n't of eaith ;. lU�`%�i "L7® J. r J� �.,'i s`,- �'�„�. �,. s.. �` Dote v�* :� , ert�f d by P E R A u ®� B ®h� z1 9845 'f ,f "P ,+�t W, '�✓ 3,.+d' a.a - 1�'� :h0 T .':n ° .. ` h k Address License No ; �. a^� x n 11 � p."'- ..,,�`� c*r t.,Y.'s} r"F .e4 _ a - ''. " •5' - ' Any person occupyng premises served by, the above system(s)�shall :proripttyItake stich action?as maybe necessary torsecuregthe correction..of.any; unsanitary < Y ;.cond�twns resulting ,from. uch ,usage ,4gpproval of the separate sewerage ystem shall become nup and,,void as soon as a 4public.sarij, sewer beco ?1es .' ' .. availab�e =and the .approval -of the,,private water'sup'I lshalh become; null andAavoid .w; a-" - ublic watt - I ,becomes •`available t ' Such�••.a� }ovals =are' < : -• P Y FSUbrect ;to, modrfication or` than`ge` when intthe,;Juiigment' of the Commissioner of- Healthy °such rev cation=';: dRi6T.,j nor -chap ef?':i's- .necessai 1: _: ¢• 'r. t ,y j, �-. " 4 �_n r .,, •y` r, ;,� *' vk ;'. gr< 7P 5 " &i g ;.`:3 �;,,. *�^ w zs ,,, , g , . Y ,� Daze �w x ¢* ' �BY y a maw v n ,Title 3 ''' v, ,r `y, `cwY� a ?S.i+'r 2" a,:�7+ z :z iC x :.,.ac r _ iQ a t A '` f -.- x +' ys t ,i s '�` s ...- 1 1 $�r, L - n, ,,.,f I v. E ^� LS+y "s s 5 t'z53 k. II' F t - .s._ ..?., h :� y , ' - x 5 i t ?r .,`"Q �, ,e�;3 �s`',t x..,,'+:z' u °�. "- -m aw_ K4'<^ 1,e.- m: r T �'s' ° f �. _: {Pi TTN A M. ('(Ii TNTY. x.ilFP A R T14tFN'T : -nF ;NF A i 'T:N. w urwsron of tnvironmentar rreartn Services, t.armer,�ni r w� u `F n x { v cs '."» r �, fi J'­, 1 t I. 1. 1t Sr r F x# x m} 1 u r,' t , x q CONSTRUCTION PERMIT FOR SEWAGE'DISPQSAL SYSTEMAS� 1 awn: of Putnam alleys Las s � e ' , c c a ou mi war e Lwe e11 Pu, S, Town or k usage Located at �fi anc� }Pee��sl� ill '1071otr'Rd. section 19 dock Par 319` Rpl „k or Subdivision TJ -' wart' of a �s Bbd lv s a on x�x' Glenn ZTelse Lot F•�D - Wlccopee'I�d. Owner Atldres O 1j Q_ F ?� � .uU- , p n -, a,!, TT . Y , ;Building.,Type ” P1� t eve Lot Area 1� 2 acr'ss Y_: f Number of Bedrooms 3 fi 'Total Habitable Space 9 Square Feet Separate: Sewerage .System Ro consist of ! > Gal Septic Tank lineal feet X - width trench .• -, r , To be constructed by Addfress a Water. Supply Public Supply From ,; _ - T L L- X Pnvate �Supply to be drilled by ` vk ,.: „ -. ll to be dug well by C71enn 1�Tel`se �- Install s� x�o :e . ° se a & a 1611 ther Requ!renients E� � ' ib1 ; � � ht1l E' � fi"n n 7 f S �.. r represent that I am wholly and completely responsible for thedesign and location of the proposed systems) 1' that the_separate_.sewage disposal _ sy" -m above described yiiill be,constructed rn shown on the�approved amendment there to and m actor 1, pce�with t iOtandards „'ruies.an re a ions o e u nam- County:;Depertment of !Health and that on completion thereof a Certificate of Construction Compliance Satksfactory to the Commissioner of Healthwill be submitted „to,_ ,the Department and a, written guarantee will be; furnished the owner his = successors heirs`or assigns by the`;builder that said bwlder'.will.' place �n >good operating: condition any part of s”' id sewage tlisposal system during the period of wo (2) years immediately following thedete of the .)ssu F 4111 n�e of,:_the approval of ,the Certrficate of Construction�Compliance of the original system or any repairs 1i , < drilled,well described above'',. -_ will be located as shown on the approved plan and that said well will be installed in accordance' with the standards, les and'regu of <'the Putnam L. County ;Department of Health , 9L I Date Apr .1 2 1973 • S ned p E5 X R A Adgess & '_Behr. A• da ►es= C e eida Ave Carty %eI N. Y. os12 g8L� . ,. _.. _ . ., <I . ,... , w M PP P. Y n of the building ng has bee revocat►le' for .cause or may be amended or modified when, considered necessary by the Commissioner of.,Healt en undertaken and n' ` APPROVED FOR-CONSTRUCT' This a roval ex ires one ear from the date issued; unless construction Health. Any- change or alteration. of construction: , BURGESS & BEHR, P. C. 128 Gleneida Ave. A '• G , WIM A S BUILT ALAN . t r ��� ^ G,� . ?NOTE.. TN /S /S, TO 'CERTIFY'.7"AT THE SEWAGE, DISPOSAL_ ' SYSTEM WAS CONSTRUCTED AS. INDICATED ON TWO PLAN 11 y 'AND 'TWA.T THE SYSTEM- WAS INSPECTED BY ME .B FORE -'IT t n " p ; >k' i WAS COVERED OVER_ THE .SYS'TEM WAS" CONSTRUCTED rs ;llV ACCORDANCE -WITW ALL. TWE RULES'AIVD RECrLILA °T /oiYs oF+GDlst boo C-1. , coe�ert.' M IOF TWE PUTNAM COUNTY DE_PARTMEN? "QF NEALTH_ *�, a. � iANk Cask -.C� _ - • .. - Novs E , u�r ei(T7pic�"> ". EXCEPTION'S TO,TN .ABDVE� %FANY' NOTEQ BELOW u' E }ND/V'ELVl1TlONS GiD� KITS.' YS/ELL 3 astir i is 6 b� D�EP � ctls :II ccivsr'A T o ReCq/VtM !® APPtr"ev�C \KI)b4 q.. �ARNVlr(,,.;.d:(3.o ,w N� � L 7�P:t RT i2 �TYPIC_1%k Putnam County Depaitment;of Health. Y: Division oY E4ivironmental :Health Servioes tA� Appr000d as toted Por -co DEP' T a :. : ,: .,,. " : • nformanoe. with iiEAIDUII.DING'. �> 41, ' �; :,_. / • a'' licable TL e. nd Regulatione ,of th g « Count! ©al '•'De atm' CCL FN Y.,' 10512. a..a . a \ B ent. e " a 1 i,q�;; -. gnature P 'a n� To' t:AS L PLAID! x �r, OF SEWA. G� D %SP05AL .3Y3TEM:. 3 ,/ ; .. T_P>£' 'ME'ASUREtiIErlTS tR,G V N% R ; G,N r, TOWN' 'OF" P4 TnI A-A4 . VAI4 . PUTNAM. _ C:OUNTY /V. Y. n f 34.9.3 ofsr ':r . a� -:/r q7:'4 P'r" ' >�'t�.s\ .. :4 PROVAL noted 44 s i 3� < i P , Z': i s,K EYE BU SS`, 6 i4, PC. . En9.neerin'� Lono' SUrveyni9 9 Glen Corme% /V Y4 y. 'Z' Z7 /0 __ _- ___- __________ -� ____�9_ ___ - __- __- _,�.__..-- ��-.�- -.rte .:____,__ • `___ _______...-_.___"_._______..__- LA-A - -_ tt�abut, TH IF. C 'E BUTL7 iD51- Glenn Neise Town of Putnam Valley Municipality Ralph & Glenn Neise 4 19 'RE d by onstructe 1 section Wiccopee Road Loc .-Lon - St-reet Block Split Level Parcel 19 Type Tot GUARANTY CF SEPARATE SEWAGE` SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewa:-e disposal system serving the above described property, and that it has bean cons'-ructed as shown on the approved plan or approved amendment thereto, and in accordance with the standarls, rules and regulations of the Ccanty Department of Health, and hereby guaranty to the owner, his , s -a c .-- e s sors,1 heirs or assigns, to place in good operating condition any par., C-1 S.ai&system constructed by me which fails to operate for a period o Years ininediately following the date of initial use of the sewage aispc 1 Syst­".';,_, 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 Pant- of the building utilizing the system. The undersigned further agrees to accept as conclusive the de- t_r-n,-Lnation of the Director of the Division of a-ivironnenrual Health Ser-- t --as p.-.,i].,,)ether or not �'ns C our- ty-..D epar-tment..".. of ...He alth .Lailare of the system to operate was caused by the willful or negligent of the occupant of the building utilizing the system Da .ed t h i s day of �o v- 19'*>Y Signature 2Mj --;eA IF Building & Septic Contracors. Titl e If borD oration, give namie ( and address)* COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE 0_2'R'TfIFICATE OF COMPLETION WILL BE ISSUED. G7-,-A-- lop, TS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.. — -- - - - - - - - - - - - - - - - --- - - - - - - - - - - - - - - - - - Z)--Lv-'s--" on of Environmental Health Services, Putnam County Department.of Hlealt!^_ -PUTNAM CO. HEALTH DEP'T_ COT UNTY U '- BUILDING o,; CARMEL, N. Y. 10512 This report is to 71dg. department, water samprle indii TOWN OF PUTNAM_VALLEY WELL DRILLERS LOG AND REPORT WELL COMPLETION REPORT be completed by well driller and submitted to together with laboratory report of analysis of sating water is of satisfactory bacterial quality. Well Location Tax Map Street / Sec. B1. Lot Well Owner Well Driller (,- Name 1 Mailing mss City 1. #S 0 ,e s s -City `emu %'1�t7 CASING DETAILS YIELD TEST WATER LEVEL SCREEN DETAILS Length ®C� Ft.1 6 / Bailed or Pumped Hrs.IStatic: Measure from land Ft. surface Make: Diameter: L.Inches Yields GPM When Bailed or Pumped Fta Slot Length F ±.Size Kind: Diameter In. TOTAL DEPTH OF WELL D ' Feet WELL LOG Depth from Give description of formations penetrated, such Grottnd.:;S:urface 'y as :...._peat., ,silt, sand, gravel, _:.clay,- ,hardpan, shale, sandstone,:granite, etc. Include'size of gravel (diameter) and sand (fine, medium, coarse), color of material, structure, (Loose, packed, cemented, soft, hard). For example: O ft. to 27 ft. fine, packed, yellow sand; 27 ft. to Date Well Completed Date of Report Well Driller2/ BZS 1 -77 Signature 11 TOWN OF PUTNAM VALLEY WELL DRILLERS LOG AND REPORT WELL COMPLETION REPORT This report is to be completed by well driller and submitted to '�Id,g. department, together with laboratory report of analysis of water sample indicating water is of satisfactory bacterial.quality. Well Location Tax Map Street Sec. BI -0 Lot Well Owner Well Driller C. Name Mailing Ac=Lvss city `7t. C r' 1. # ess / City (J it CASING DETAILS YIELD TEST I WATER LEVEL SCREEN DETAILS Bailed Measure from, and.surface Length l Ft. or / Pumped Hrs.lStatic: Ft. Make: r/ When Bailed i Slot Diameter: Inches Yield: GPM or Pum ed Fta r. Length Ft.Size Kind :_ _ tit I Diameter I_n._ TOTAL DEPTH OF WELL Feet WELL LOG .,:Depth from Give description of fnrmatiohs penetrated, such ..Ground Surface as: peat, silt,. sand,.gravel, clay, hardpan, -- shale, -- sandstone; - granite, --etc; ° gravel (diameter) and sand (fine, medium, coarse), color of material,.structure, (Le-ose, packed, cemented, soft, hard). For example: O ft. to 27 ft. fine, packed, yellow sand; 27 ft. to Date Well Completed :Date of Repo rt Well Driller/ BZS 1 -77 Signature ROY BURGESS PROFESSIONAL ENGINEER LAND SURVEYOR BURGESS & BEHR, P. C. N.Y. • #9845 N.J. #2824 PROFESSIONAL ENGINEERING & LAND SURVEYING - PA. - #8454E R. D. B - HORSEPOUND ROAD MD. - #3063 LA. #4522 CARMEL, N. Y. CARMEL 5-3312 (AREA 914) June 11, 1981 Putnam County Dept of Health County Office Building Carmel, N. Y. 10512 Re: Construction Compliance Glenn Niese -T. Put Valley Gentlemen: We are enclosing four prints of the sanitary system, as built, on property of Glenn Niese, and which w e have been holding since November 1.974, awaiting the other items which normally accompany a submission of such plans. ALVIN H. BEHR LAND SURVEYOR N.Y. • #37707 CONN. • #5394 We have had the Contractor's guaranty all this time, however_, we have•just received the report on the water supplg -and the - bacterial -- tests ... -__ Mr. Niese has been occppying the premises, probably since 1975 and has just now felt that he needs .the `tas built" system approved... Please.send the approved prints directly to him, at: Mr. Glenn Niese Wiccopee Road Putnam Valley, N. Y. 10579. Thank you. Very t7�uly .yours, BURG SS & BEHR, P. C/. By. .,Ti . ," •, I7 enC �t s."CE BUNW011 �f Y )512 u' N 15 1981 ti Gentlemen: DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date March 20, 1973 _ -:.... -- _ - Re: Property of .east side uiiccopee rcl, oout 'rill between F-Undin. St and Located at Peekskill Hollow Rd (See Location Map enclosed) Section 19 Block 1 Lot Portion of Parcel 19 This letter is to authorize Roy Burgess a duly licensed professional engineer X or registered architect (IndicaT_eT- to apply for a Construction Permit for a separate sewerage system; to serve the above noted property in accordance with the standards, rules or regulations as promulgated by the Commissioner of the Putnam County Depar tii,cIIU of Health, and to sign cLl1 riec essary papers on my behalf In connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or :.. ,.._._......_. 3 7T Edt Eatzen - Law, the-- Public - Health-- -Law; .and.- the --Puts haft�- Gouty- Sang-. tary Code. Countersigned: A 19 ct -I P.E., R.-A., # Burgess & Behr, P. C. Add ess 12f Gleneida Ave Carmel, N. Y. 10512 225 -3312 Telephone Very truly yours, 1 Signed !wl ' Owner of Property R. F. D. 1- W iccopee Rd, Putnam Va e-,� ss SO pA0FE33WNP�� r i r y 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. 303J- 515 Owner Mr..: Glenn IT:Lase Address R. F., D.' 1- Wiccopee Rd., Putnam'Valle .' east side 1,•Jiccopee lid, about midways bet we _u in and Portion 19 ...Located at (Street. eekskill Ho7_loti�r. Ptdsec. Block Lot - See Location Map (Indicate nearest cross street) 1: encloled Putnam Valley N Y. Cit. Municipality Y Watershed y - i SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS ITT 1 _ Number. CLOCK TIME ..PERCOLATION PERCOLATION Run Rl apse, Depth to Water a er Level No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in dr6p ` Inches Inches Inches .11:00-1-:0.6. 61 19 18 1 6 or . i :06 -1:12 6 19:.... 18 1 6 rr X1.12 -1:18 ..6- 19 18 6 5 11:oo -1 :o6 6 ..19.. 13 6.rT 2 1:06 -1:18 12 1:9. 17 .2' 6 31;18 -1:2L 6 19 18 l .6 rr 3 _ i -, 5 ;. Notes: 1) Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation.test hole: All data to. e submitted for review. 2 Depth measurements to be made from top of hole. /, Ili PUTNAM COUNTY DEPARTMENT OF HEALTH b c DIVISION OF ENVIRONMENTAL HEALTH SERVICES �i 0 o WELL COMPLETION REPORT 5a. j 0 �y irelrI:ocation ­ -.. Ktreet Add ss: 3 (� 7 ! �,� EM,,2/jjMap Tax Grid # �z,3_o6y. Block Lot(s) Well Owner: Name: Address: Use of Well:_ 1- primary 2- secondary Residential Business Industrial Public Suppl Air cond/heat pump I iga on Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment _ Rotary Cable percussion Compressed air percussion Other (specify) Well Type' Screened Open end casing �4-_ Open hole in bedrock Other Casing Details Total length 3 ft. Length below grade Z I ! 'ft. Diameter in. Weight per foot a lb /ft. Materials: -?C Steel Plastic _ Other Joints: _ Welded Threaded Other Seal: -` Cement grout _ Bentonife Other Drive shoe: - Yes No r Liner _ Yes X' No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours 2d Yield tOtgpm Depth Data Measure from land surface- static (specify ft) 12- During yield test(ft) Depth of completed well in feet 17 Well Log If more detailed information or descriptions or siexe_analyses.. are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface �I ' 1qD _ ..... _..... _._�_ _.. If yield. was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type .,� . Capacity Depth WW1 Model Voltage 2ju HP t Tank Type Volume Date Well Completed Putnam County Certification No. Date of Report Well Driller (signature) 5 NWE: Ukact location of -well with distances to at least two permanent landmarks to be provtaeci on a separate sneev_pt�an.- Well Driller's Nam e /��� Address: �� Y _ ,���► Signature: `� �i��.� --J Date: White copy: HD File; Yellow copy = Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 v 12" „ 18.. IS and y loam, trace :clay 30„ „ 36„ 4 it 4811 ++ _ } ". sandy gravel . 72" .. . ,t 1 _ 78„ �� r =- :IlVDICATE LEVEL AT WHICH GROUND WATER IS ENCWER TERED none _.INDICATE LEVEL TO WHICH WATER LEVEL RISES A BEING ENC OUNTERED -none TESTS MADE BY Blaraess RA, Behr,, P, Co Date 3/22/ 73 t DESIGN Soil Rate Used 6. Min,/1 "Drop: S. D. Usable Area Provided 3500 No. of Bedrooms 3 Septic „Tank Capacity 900 Gals. Type Precast Absorption Area Prov de , L.F.x24” 3611 ": width trench., 5 + -0 Six seepage Jpit 5 - by • eep - Other . ame i„rgess Signature _ _ Address Burgess Behr, `P.. C. SEAN ; s4���0� N�y,koq 20 G enel a 4ve, C arme N . Z . �. __. THIS SPACE FOR USE BY HEALTH- DEPARTMENT ONLY:. ' w, Soil Rate. Approved Sq.'Ft /Gale Checked b e e �FESStO�P PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL - - please print or type PCHD Permit # / y ✓ ' Well Location: Street Address: Town/Village Tax Grid # f 3� Map Block Lot(s) Well Owner: Name: Address: elan N, -es-P— 1 /-3 (a 0 &Coe le A I I e (35 -1 Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served )�- Est. of Daily Usage gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason rn pre A+ei'- !G-4PPIV for Drilling Well Type V Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision i` oyi Lot No. Water Well Contractor: e ; rA Address: Is Public Water Supply available to site? ....................... I........................................ Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to b vided o separate hee, /plan. Date: S.—JO Applicant_ Signature:. PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well ler certified by Putnam. County. Date of Issue d ! "J 00 Permit Iss ' Official: Date of Expirati ® Title: Permit is Non - Transfer abl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 ` YML ENVIRONMENTAL SERVICES � 321 Kear Street (914) 245-2800' Albert H. Padovanin Director � LAB #: 32.108224 CLIENT #1 10364 NON STAT PROC PAGE ! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ NIESE. GLENN DATE/TIME TAKEN�n 11/21/01 05�30 136 WICOPEE ROAD DATE/TIME RE['D� 11/27/01 O2:')0 PUTNAM VALLEY, NY 10579 REPORT DATE, 11/28/01 PHONE; (9i4)-526-3742 SAMPLING SITE: 136 WICCOPEE RD, PUTNAM VALLEY, NY SAMPLE TYPE../ PGTQ6L[ : KITCHEN TAP PRESERVATIVE5L NDNE COLM BY: GLENN NIESE TEMPERATURE..' < 4� NOTES...: COLIFORM METHN X:' ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHUD � 11/27101 MF T. COLIFORM ABSENT /100 ML ABSENT 1AO8 CGAMENTS: � BACT THESE RESULTS INDICATE THAT THE WA�E WAS NOT> �F A SATISFACTORY SANITARY QUALITY ACCORDIk����^�HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS4 iFOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. SUBMITTED BY: ~ Director ELM 10323 a TOWN OF PUTNAM VALLEY WELL DRILLERS LOG AND REPORT WELL COMPLETION REPORT This report is to be completed by well driller and submitted to 71dg. department, together with laboratory report of analysis of water sample indicating water is of satisfactory bacterial quality. Well Location Well Owner Name Well Driller C Name Length / q Ft. 1p Street Mailing Act •�'G�l /l /� iJ!/ 6 #i - Inches I Y or Sec. 81. ei,et-X,L�Z�4/ Ys Cit ordm j1. #/ Address Hrs. IStatic: When ty Ft.I Make: t ,9 r N DETAILS face Slot th F t. Size er In. TOTAL DEPTH OF WELL ?e9 Feet WELL LOG Depth from Give description of formations penetrated, such Ground Surface as peat, silt, sand, gravel, clay, hardpan.,_„ _ __ ..._._ _. »..... _..:_ _., s�r�►le; -sandstone, -- granite -,= etc. Include size of gravel (diameter) and sand (fine, medium, coarse), color of material, structure, (Loose, packed, cemented, soft, hard). For example: O ft. to 27 ft. fine, packed, yellow sand; 27 ft. to Date Well Completed Date of Report �1 Well Driller 7/�i >'"a'~� Signature BZS 1 -77