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02616
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02616
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
I 572. - 3 - G
ell )l;ocafon 'Street
Addre s: , ._
130 A ae- �r�v(�
To /Village: �j
�
Tax Grid #
Mape Block Lot(s)
Well Owner:
Name: Address:
Use of Well:
1- primary
2- secondary
Resid ntial Public Supply Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion Compressed air percussion Other (specify)
Well Type
Screened Open end casing Open hole in bedrock _ Other
Casing Details
Total length 9 ft.
Length below grade �'
Diameter in.
Weight per foot le- lb /ft.
Materials: 2!C Steel Plastic _ Other
Joints: _ Welded Threaded _ Other
Seal: _ Cement grout _ Bentonite Other
Drive shoe: ?.Yes _No
Liner _ Yes _J,:� 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
Yield 10 gpm
Depth Data
Measure from land surface- static (specify R)
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
sieve analyses
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameteron)
Formation
Description
ft.
A.
Land Surface
;2
v2j
it
✓r
r
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information -
Pump Type 3 ,rye Capacity S
Depth 3OU Mode14ao
Voltage 2_�36 HP i
Tank Type i ✓X 2Sv Volume< .s
Date Well Completed
Putnam County Certification No.
Date of Report
We I Driller (signature)
nv i m rxact location or wets witn aistances to at least two permanenylandmarks to be provided on a separate sheeVpian.
����
Well Driller's Name ���-r� ��ory, �Lzc� Address;
Signature: —717 Date:
White copy: HD File; Yellow copy- Building Inspector; Pink copy - Owner; Orange copy- Well driller
Form WC -97
� ~�=
� YML ENVIRONMBNITAL SERVlCES
321 Kear Street
Yo"..ktomn `Heigh��,c�N+y.` 10598 ' ~
(914) 245-2800
Albert H. Padnvani, Director
LAB #: 1.502473 CLlENT #: 55057 NON STAT PROC PAGE: .1
NIESE, RALPH DATE /TIME TAKEN: 04/21/05 10:50
134 WICCOPEE RD DATE/TIME REC'D: 04/2J/05 10:35
PUTNAM VALLEY, NY 10579 REPORT DATE: 04/28/05
PHONE: (845>-528-8684
SAMPLING SITE: 130 WICCOPEE ROAD, PUTNAM VALLEY SAMPLE TYPE..: POTABLE
: KITCHEN TAP PRESERVATIV ES: NDNE
COL 'D BY: RALPH NIESE TEMPERATURE..:
NOTES...: COLlFORM METH� N/A
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG PROCEDURE
PUTNAM CNTY
PROFlLE
04/21/05
IlF T. COLIFORM
04/27/05
LEAD (IMS)
04/22/05
NITRATE NITROG
O4/21/05
NITRITE NITROG
04/27/O5
lRON (Fe)
O4/p5/m5
- I44NGANESE (Mn)
04/25/O5
SODIUM (Na)
04/21/05
pH
04/26/05
HARDNESS,TOTAL
04/26/05
ALKALINITY (AS
()+/26/0�[���
.� �rURBIDITY` (TUF|
RESULT NDRMAL - RANGE METHOD
ABSENT
/100 ML
13.8
p p b
1.03
MG /L
<0.01
MG /L
0.19O
MG/L.
O'.036MG/L
55.7
MG/L
6.7
UNITS
232
MG /L.
46.0
MG/L
lVTU.
ABSENT
0-45 ppb
0 - 10
N/A
0-0.3 mg/l
0-0 3- /1
. mg
N/A
6.5-8.5
N/A
N/A
COMMENTS:
BACT THESE RESULTS INDICATE THAT THE WATE (WAS NOT) OF A
SATISFACTORY SANITARY QUALITY ACCORDIN��f�'THE NEW YORK STATE
AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS
TESTED, AT THE 'TIME OF COLLECTION.
�
Pb/Cu LEAD limits for public schools are set at 15 ppb.
EPA Lead & Copper Rule for Public Systems reqt-tires that no morez
than 10% of their distribution points have a LEAD value of more�'�
than 15 ppb and a COPPER value of 1.3 mg/L, else water �
u�
treatment must be undertaken to reduce the waters corrosive
potential.
Fe/Mn If both iron and manganese are present, their total value
combined shall not exceed 0.5 mg/L.
,
`
Na No limits for Sodium are., proscribed� Suggested guidelines state
that for people on a sodium restricted diet,the water should
contain no more than 20 mg/L. of Sodium. For those on a
moderately restricted diet, a maximum of 270 mg/L. of* Sodium
1008
9O03
90152
9l62
9002
9002
90O2
9O43
/
9001
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APR-15 -2008 12:55P1t FROM - ENVIRONMENTAL HEALTH 0452787821 T -283 P.002/002 F -188
- D Il_Q- IRONMEI7, FiAL
PROPOSAL F0,13 SoffA
RE REPAIR E
YES No al Use On PERMIT
Repair Permit issued In last 6 years tin a rs
Repair within 9dyd s Comers, W. Branch or CnAun Falls Res, Delegated
o 6P Repair within 200 ft or a waterooursa OF OEGppmapped wetland 'tQ Joint Review
SITE LOCK ON �� TOWN f(fIV A IM U41kY TM # c� . -J 40 .
OWNER'S NAME d PHONE # S9r.-C-- J
MAILING AdDRESS�
Name & Relationship (La., m der, tenant, contractor) r r
DATE Jp $ FACILITY TYPE t'S ilel?14, a t 1 PCHQ COMPLAINT #
PROP03E17 INSTALLER
ADDRESS - l REGISTRATION /LICENSE*.
Proppsal (include a separates etch locating the house, property Imes, all adjacent wells within 200
That of repair and the location of existing and propoeed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair. A -.--Y O —1 A,
I, as owner,agree to the conditions stated on this form
SIONATLJRE is _ J ITLE Q�%J�41� CRATE
(owner)
1, the septic instal arm to comoiv with the conditions of this permit fbr the septic system repair
SIGNATURE TITLE & /
fee rt . r DATE
(installer)
Proposal aaan3y d with a oll g conditions:
_... 1..: Procurement of.any Town.Pemnit, if 3ppiloble._ _.: m...
2. Submission of as built repair ®ketch by the septic- system installer within 30 days of the repair, In duplicate showing:
- a. Owner's nave, Site Street Name, Town and Tex Map number
b. Location of Installed components tied to two tined points
c. System description (e.g., 1250 gal. Concrete septic tank, eta.)
d. Installers' name and phone number
3. System repair to be performed In accordance with the above proposal and conditions
4. The proposed SSTS repair Is considered a best fn design and there is no guarantee to the duration at which the
completed SETS repair will function. .
S. No completed worts is to be backfilled L"ll authorization to do so has been obtained from the Department.
INTI KNAL Ubr. UNLT
Proposal Approved _ S Pro o al Denied S
4., , 02. e4 -
Da e
5
COPIES: PCHD; Owner, installer
PC-RP 99ML .
Rev. 2107
.0 .. ,:5 '. 1f .. v.,Y... i .`:Y •.4'. ".Ali... -. . c._ �i. ar_ amavr.., rw,:.... r. �., a. c. w.. cu.. rn. ra.. �.. i.-..... r....- �... w........ �..., �...... r................. w. �....... ..e�.,_.r._- ......x�,......_... _..._�.. ..
ZOO /Z00 ' d 9V L # E L : Z L 8002 /g L /b0 BO L S b9L ELS L Aquno0 11V a.lp3 41.ap3 : W0.a3
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR "O
YES Internal Use Only PERMIT
Repair Permit issued in last 5 years Not in Watershed
Repair within Boyd's Corners, W. Branch or Croton Falls Res. Delegated
* Repair within 200 ft. of a watercourse or DEC - mapped wetland * Joint Review
(SITE °L CATION J OWN c�'� o, V41) v
�x
OWNER'S NAME y1� Gl�1c PHONE #�: �l -J-
MAILING ADDRESS , f , �► 17 T
APPLICANT COF,;gi)� a f1 -d�1S C�LsD�h�
Name & Relationship (i.e., ow der, tenant, contractor)
DATE (J FACILITY TYPE grj p� a PCHD COMPLAINT # +
PROPOSED INSTALLER r A4 -PHONE#
ADDRESS Apk - ,a A l po' REGISTRATION /LICENSE #
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.
I, as owner,agree to -the conditions stated on this form
DATE ±
T
I, the septic installer, agree to com ly with the conditions of this permit for the septic system repair
SIGNATURE , .. TITLE C�ttt tf DATE-- -`—�`�
(installer)
Proposal approved with the following conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's nave, Site Street, Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
Proposal Approved <_ Proposal Denied
'3 ^®
Repair proposal is in compliance with applicable codes:
Ubt• UNLY
<
5 0
Da e
Yes < No s
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
SHERLITA AMLER, MD, MS, FAAP
Commissioner_ of Health_
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
Date:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
FAX COVER SHEET
ROBERT J. BONDI
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
To: z r S A Fax #: °l 7 3 76 V- 9/y&
No. Pages: ;Z
(including cover sheet)
From: Gene D. Reed
Putnam County Department of Health
/For your information Please respond
F r your review Attached as requested .
:..:.. ......_ As discussed _ ._ __ °_: _ _. e Please call ......_.. - - _ _...._ -
Notes/Messages,
i
°
In the event of transmission /reception difficulties please contact this office at
(845) 278 -6130, ext. 2261
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 -Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648
shect I of j
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISIQN.O.T�- T-.AL:U-EA-,T- L11- SERVIC -S--.�
FIELD ACTIVITY REPORT
Street
PERSON IN CHARGE
Town
4),441 44---TZWAA1Cd
ng mTF-RvFFvTFT)-- Aimni�c-Azze:-14W c,:,uvz-)/
Name and Title
TYPE OF FAC.ELITY: 7Z 4�7p
,417Z,
State
Zip
FINDINGS: a 7;;hJw- 411-71-v 'coo Rvan- nA2k
.11V -5,441a
Signature and Title
REPQRT'R'F.C-F,TVF-T-)RV:
I acknowledge receipt of this report: SIGNATURE:
0219 6 Title:
EI.T'I' T COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO ABANDON A WATER WELL
please print or type PCHD PERMIT # tgWg7'
Well Location• Street Address: TownNillage Tax Grid #
• f � Lj t`L� ( a_ �,�-', vult . MapSl.vBlock j Lot(s)
ell Owner:
Reason For
Abandonment:
Description of Work To Be Performed:
+Z� +0P LAJ'��
Date: /�' Lo d Applicant Signature:
L'' ` -% 1 '
This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR
and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall
submit to the Department a certified statement that the ' o ation delineated on the application for this
permit has been completed.
i
�S
Date o ssue Permit Issuing Official Title
White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WA -97
Iv tL
.5�AmA'
Well Type:
Drilled
Driven Dug
Gravel Other
Depth Data:
Well Depth
ft
Static Water Level
ft JDate
Measured
Use of Well:
Residential
Public Supply
Air /Cond/Heat Pump Abandoned
1- primary
Business
Farm
Test/Observation Other (specify)
2- secondary
Industrial
Institutional
Standby
Water Well
Contractor:
Name:
-1 ,jam,,,
Address:
1" %.S
_-�' 7
Reason For
Abandonment:
Description of Work To Be Performed:
+Z� +0P LAJ'��
Date: /�' Lo d Applicant Signature:
L'' ` -% 1 '
This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR
and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall
submit to the Department a certified statement that the ' o ation delineated on the application for this
permit has been completed.
i
�S
Date o ssue Permit Issuing Official Title
White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WA -97
(i �• -t*- /ate Y �J J Y /
PUTNAM COUNTY DEPARTMENT OF HEALTH
Q DIVISION OF ENVIRONMENTAL HEALTH SERVICES
p
APPLICATION TO CONSTRUCT A WATER W_ E_ LL.,
__..e.... please print or type PCHD Permlt # 14/1 J to — O L/
Well Location:
Street Address: Town/Village Tax Grid #
,,3--6
c, 12J) ti- iiu.y,,. �� Map Block Lot(s)
Well Owner:
Name:
JAddress:
Use of Well:
x Residential Public Supply Air /Cond/Heat Pump rrigat' n
1- primary
Business Farm ' Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought 3— gpm # People Served 9 Est. of Daily Usage _gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
('�� i� ?ti %�L� ,�� h , `,� j N
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? ...................................... ............................... Yes No
Name of subdivision Lot No.
Water Well Contractor:: V,; - Address: icy f v, 4 h, lrw /Abg
Is Public Water Supply available to site? .................................. ............................... Yes Nom
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Date: 4- -2 8 : y -'-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. An revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water ller ce ified by Putnam
County.
% r
Date of Issue ,/ V Permit Iss ' fficial:
Date of Expiratio !� Title: `
Permit is Non - Transfer abl
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
LORETTA MOLINARI
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
Norman Anderson, Inc.
152 Barger Street
Putnam Valley, NY 10579
January 4, 2005
Dear Mr. Anderson:
ROBERT J. BONDI
County Executive
Re: Proposed Well O'Dell Estate
130 Wiccopee Road
(T) Putnam Valley
52.-3-6
A field inspection was conducted on the above referenced lot by Briaai Stevens, Public
Health Technician. The application to replace the existing well is approved with the
following stipulations:
1. The existing well is to be abandoned once the new well construction is
complete. Please provide notice to this Department five days prior to
abandoning the existing well so that this Department may witness it.
A Well Completion Report (WC -97) shall be submitted no later than 30 days after the
well completion by the permittee.
Please contact the writer at (845) 278 -6130 ext.2235 if you have any questions.
Sincerely,
Brian R. Stevens
Public Health Technician
cc: RM, file
LETTERS TESTAMENTARY
-File No.. 218/2004-
r- .....:- _.- -
THE PEOPLE OF THE STATE OF NEW YORK
SEND GREETINGS: TO THE FIDUCIARY(S) AND OTHERS CONCERNED:
Letters are on this date granted by the Surrogate's Court of Putnam County, New York,
as follows:
Name of Decedent: VIVIEN 0-'DELL
a /k /a VIVIEN D. O'DELL
Domicile of Decedent: Putnam Valley, New York
Date of Death: November 6, 2004
Name of Each Fiduciary: VIVIEN NIESE
Date Will Admitted to
Probate:
Type of Letters Issued
Limitations on Letters
December 3, 2004
LETTERS TESTAMENTARY
NONE
THESE LETTERS, granted pursuant to a decree entered by the Court, authorize and
empower the above named fiduciary to perform all acts requisite to the proper
administration and disposition of the estate of the decedent in accordance with the
decree and the laws of the State of New York, but subject to the limitations, if any,
as set forth above. _
Dated: December 3, 2004
IN TESTIMONY WHEREOF, the seal of the
Surrogate's Court of Putnam County has been
affixed.
WITNESS: Hon. Robert E. Miller, Surrogate of
the County of Putnam.
Chief Clerk of the Surrogate's Court
THESE LETTERS ARE NOT VALID WITHOUT THE RAISED SEAL OF THE COURT
A C K E S
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