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02906
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02906
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
please print.or_type :. _ _ -- ._ _ ... PCHD Permit
Well Location:+
Street Address: -~ �W TownNillage Tax Grid #y 2miS'- 7-
u gtrn R1) PAO C' vd le gi Map Block Lot(s)
Well Owner:
N e:
S -✓cry 4 q5x�
Address:
I y Art Aueo V,
' lvev 0 11 NV ad/
Use of Well:
Residential Public Supply Air /Cond/Heat Pump Irrigation
primary
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought S gpm # People Served 3 Est. of Daily Usage 3 6O gal.
Reason for
Y\ Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed - Reason
e ks. SPaso
for Drilling
q
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? .................... .................. Yes. No
...............................
W �
Name of subdivision i yha i ho � S Lot No.
l
Water Well Contractor: Address:
Is Public Water Supply available to site? ........... Yes No SC
Name of Public Water Supply: W' 14W ° A
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided n separate sheet/plan.
Date: 7 �s �- 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 driller certified by Putnam
County.
Date of Issue J Permit Issu' g Official:
Date of Expiration 3 —7 --Oq Title:
Permit is Non- Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
J
lit. Y
DEPARTMENT OF HEALTH'��__ �� • 6 S
''° Division .of Environmental Health Setcea ` 3
110 OLD ROUTE SzR CENTER; CARMEL, N.Y. 10512 i ±
`K_ i�Pt'�,,1 "l.Alil/lb `1'li C.C11y5'1'itUt:l' A I�I1`I'b:k WEi'L
'.�'�%L�q '.o ' r+" •:.1�' `�. 4�'.. .f:Wt6C4F3�9.lt�L. i{ �:. 2 ."�icGT1L�.`�n�.Ei- :i`i+h�Y,t.. i.S; 4•f i:'.± a.. .. .... ,.. ... '. r .... .l.n S.r. . 5
Y PrUn AF!PMTT
WELZ,'LOCATION:
`Stet "3Address
Town Village City Taxi Grid Number
WELL:._OWNER ..:.......
t. .. ..._. .._ Al.. ......._
Mailing - ' -
Address r / �r y,�tae J i L;
SE.: LL,
RESIDENTIAL .
D PUBLIC SUPPLY
Q AIR /COND /HLfAT PUMP 0 ABANDONED
primary
2. -'; secondarQ
0 BUSINESS"
0 .INDUSTRIAL
O FARM. O TEST /OBSERVATION OT$ (specify
C3 INSTITUTIONAL:- O STAND -BY +-2 ;;.:.: �;
AMOUNT OF USE
YIELD SOUGHT ' 4 'gpm /#
REPLACE, EXISTING SUPPLY ..
PEOPLE SERVED S' /EST . OF DAILY USAGE 3 al
O TEST/ OBSERVATION E2 ADDITIONAL SUPPLY
REASON . FOR .
DRILLING
O NEW SUPPLY
NEW DWELL. IN-61
® DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
�RILLED
; . ,�
DRIVEN
DDUG
®GRAVED
®OTHER
IS WELL SITE SUBJECT TO AIDODING? YES ✓.NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ,e,t/Dc -[_S
Lot No.
WATER WELL CONTRACTOR: Name ie4oN
n Address:
IS PUBLIC WATER SUPPLY AVAILAB11'98 SITE:. ✓"✓ YES NO (5;?e_ 90W0_
NAME ' OF PUBLIC WATER SUPPLY: WrLf y-A: ok."' 4VO1 -05 /' �,V41/1W% /VIL /CITY P07-,VjW
'- -�►t�- Ott -—
_.. DISTAiICt s0 : z�3sPR'Y = RO?�T`'- r.�`EST_ idATER _MAIN:._.'
` t ��issa =oaf /ui';f%�ci
LOCATION SKETCH_ &SOURCES OF CONTAMINATION 'PROVIDED --�.�X
ON SEPARATE SHEET
(date) (signature)
I) R,_movai of pits to be witnessed.by Put. Co. Health De t. ricr to k (?r!L constru/ n 2) well
by a .ie
be installed. 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 S 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'shali take appropriate'action;to' assure that
any' -and all water or waste products ,from.'such':•well.dril g operations be contained on this
.property and in ner as. not to degrade or of ont irate surface or groundwater.
Date of Issue: �,: ,:
daze of E , 1_ratio d P it Issu c ° A mrrcv
_ iaat Hsa a,
' }r` it ie Non -T f " . .s 41 Vie, co HD 'Fi3br'Y Pr6tt sr, rte}
e
NrJS *a �lOw Leo $leg, p. Orange copy Wei Driller
Ins
., spgzoved b;� specific waiver xeer'adTraiyer ar..rest�rictions:
2: l
STATE DEPARTMENT OF HEALTH Specific Waiver
oI Community Sanitation and Food Protection from Requirements of Part 75 and Appendix 75- A,10NYCRR
. - ....f6r .tni �r s cw�!d� ra7�Tr33rn£r!YR, s +8c
.1310Ivia4 t _ ..,.,.._.
SW -11 -97
Name of Applicant Sperling
No. Street Qty/Town State zip
Address 21 Southern Road Putnam Valley NY 10579
Site Location 21 Southern Road
1. Reason why site does not meet 10NYCRR Appendix 75 -A (check appropriate box(es)): .
Separation distance cannot be achieved.
Excessive slope.
J High groundwater.
I
Inadequate depth to bedrock or impermeable layer.
Soil unsuitable.
Other(explain) .......................................................................................................................................................................... ...............................
f.............................. ......... ........................................................................................................................................ .....................- .........
:
................................................................................................................................................................................................................•---•-•---•--........................................................---
2. Proposed design or conditions of waiver:
j 85... fe. et ... to... a ... SSDS.,.... ult .ra ... vio.l.et ... d.isinf act-ion ... system .... to .... be ... insttalled -, well ... to ... be
doubled cased. Removal of grey water pits to be witnessed by a representatsive
f of '-the..Ffe'aTtFi' D'epartmeat...prioFto ... th'e..well construction. Well location to be
stake. d ... b. y. ... a... licens .ed._.survey.o.r.,....lo cation .... t. o... be ... c. onfirmed ... by- •_a...representa t: ve ... of
`..._. .__...t?he._Hedlt•_.; .Dep rt^ t p -nicer- to. thc• li- corest•ruc �cag
.......... ................ .......... ............................... .
............. .........................................................................................................................................................................................................................._............... ................... ...........
.
i 3. The proposed design may have the following limitations (check appropriate box(es)):
I
i J Increased risk of well or spring contamination.
Increased risk of surface water contamination.
j Expected design life of the system will be diminished.
Operation of sewage system is subject to mechanical problems.
Other (explain) ............... ............ ...................................................................... :........................................................... ........
........._........._ .._.
:............. ............. ........................... ... ........................ ........... ............ _ .................. .... ...._.._.._ _
I
........................................................................................................................:....................................... ...............................
! Additional information attached
i
Construction pursuant to this waiver request should not pose any foreseeable health or environmental problems. In accordance with
New York State Department of Health Administrative Rules and Regulations, Part 75.6 (b), a waiver is hereby granted. This waiver
may be revoked by the issuing official for a change in conditions for which this waiver was granted.
ORIGINAL - Local Health Agency
COPY - Applicant/Design Professional
(GEN -152)
—Text 12
/JICT I.D. NUMBER 617.21 SEJ0R
Appendix C
- -• - - - _ _ .- -- ,� .. ,_, - _ .., . ' �.: C$- +�s^ :aF3i'ST�t:ai�$�'vi:8iii+)' t"iv"viEiiftr - - .. .. ,
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
2. PROJECT NAME
.SRerling
Wildwood Knolls
3. PROJECT LOCATION:
Municipality Putnam Valley County Putnam
4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide -map) •• -
21 Southern Road, Putnam*Valley
TM X662.15 -1 -25
5. IS PROPOSED ACTION:
�i
❑ New El Expansion A.i Modification/alteration
6. DESCRIBE PROJECT BRIEFLY:
Construction of a water well
Removal of gray water pits
7. AMOUNT OF LAN AFFECTED:
/ 1/4
Initially acres Ultimately acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
❑ Yes ❑ No If No, describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
au I Residential El Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other
.....Describe:.
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL)?
❑ Yes ®No If yes, list agency(s) and permitlapprovals
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY-VALID PERMIT OR APPROVAL?
❑ Yes UNo If yes, list agency name and permll/approval
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION?
Q Yes Q No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant/sponsor name: Date:
Signature:
1. APPLICANT /SPONSOR
If the action Is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
1
it
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PART II— ENVIRONMENTAL ASSESSMENT (ro -be completed by tigency)
A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF.
❑ Yes No
A. 111 nTl r A TCf� tCG v ..
T S 'S t �} n n •'+iz Gn to n n r
�?)iAII).,�31_��1?�tiy 14 R .t1t. �f1 w1b' +.ai�i....;.�, ..rF.'t�,NJ t'.x.ri�'n F+6Et, -...s•a ., . ,�t;�lgr a= ����t•Y. @:4'9�slRrsflcu�
may be superseded by another Involved'agency..
[]Yes o
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may handwritten, If legible)
C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erosion, drainage'or flooding problems? Explain briefly:
1�
C2. Aesthetic, agricultural; archaeological, historic, or other natural. or cultural resources; or community or neighborhood character? Explain briefly:
0 USei
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or•threatened or endangered species? Explain briefly:
C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly
C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly.
C6. Long term, short term, cumulative, or other effects not identified in Ci-05? Explain briefly.
9D
C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly.
�b
D. IS THERE, Off IS TFIERE LIICEIY TO BE, CONTROVERSY RELATED TO POTENTIAL AOVE�SE ENVIRONMENTAL IMPACTS? "'�
❑ Yes E;rwo If Yes, explain briefly
PART 111— DETERMINATION OF SIGNIFICANCE (ro be completed by Agency)
INSTRUCTIONS: For each adverse effect Identified above, determine whether it is substantial, large, important or otherwise significant.
Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural);,(b) probability of occurring; (c) duration; (d)
irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed.
❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL, EAF and /or prepare a' positive declaration.
Check this box It you have determined, based on the information and analysis above and any supporting
documentation, that the proposed action WILL NOT result in any significant adverse environmental Impacts
AND provide on' attachments as necessary, the reasons supporting this determination:
Namead Agency
Print T pe Name of Responsi e Officer in Lead Agency Title of Responsible O icer
. Irro�-
SiglatWo ponsible Officer in Lea Agency Signature of Freparer (it dillerent from responsible officer)
'Ti ate
12
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Putnam County Department of Health
..
Tvices
One Geneva Road
Brewster, NY 10509
Attn: Dan Hadden
Steven Kozak
4 Park Avenue, '21 V
New York, NY 10016
Dear Mr. Hadden:
I am applying for a water well permit for a property on 21 Southern Road,
Putnam Valley, NY, 10579. 1 am enclosing-the application, the short
environmental assessment form, the specific waiver, and the $100 application
fee. Because this property was approved for a well in 1997, 1 am also enclosing
a copy of the prior approved permit.
I currently have an agreement to buy this property, contingent on obtaining a well
permit.
Thank you for your consideration in this matter.
Yours truly,
Steven Kozak
�1�1az
V .Q
I
OWNER I S NAME > i --- L
SITE LOCATION
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_ .. 225 -0310
P10 I-OR SAGE- U15PCb-AL SYSTIEk REPAIR
kL Ftz0 J+
PHONE Sl 6
TO
PERSON IlVTERVIEWID D2 ie1 rJ Oc"J"j' 2 H 6 - -r,J f PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY 5
PROPOSED INSTALLER C PHONE Zs- - C7 7 �}
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect. -To // j /
t!M c J C � �j S '1- ..-./ G /J� � 'I -Y..�- I S I P �f"�i I- iC,
L L r i,J -L-1 J 1g Kr Z - s 4,/6
I f�1 rl �. % nl �r/s -r k �L 2.- . 12 i 611 111 c S l �.l
- '�ci5-� r✓� �N s4T--,:�, Lb,; r, 2_ G.s►A 'ft� Co�/u�S
Proposal approv Proposal Disapproved
Inspector's Signature & e ter
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. SuYmisgion of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed ecmponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywalls surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner�or reported agent of owner agree to the above; conditions.
SIGNATURE 1 � '�- (P,t�� TITLE 4 6 &-/'� DATE A/u
PINS: WAte MD); YeuQw (fin SL); Pink Oqi icw t)
f
P.A. Box 621
CARMEL, NEW YORK 10512
.... (914) 226 -6277 - _ . . . . .. _ ...
4- ql ri.
DcLTA •l
-urip r
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e4'c� - t `
�� ���- ripe �- N ����. �. ���+�•
n a
Nov l ( 1993
r-k o ` r4flq '
� � :2
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
.please print or tvpe ... a - . ^T FT_{.: Pte, - it �! _�� � '�►._
Well Location:
Street Address: Town/Village Tax Grid # 2'W/r- ! -
S o v Att�'? Rb, Un4m V411,ef 0 Map Block Lot(s)
Well Owner:
Name:
fin Ask
Address-
I ;; Aufot yo�k
Y I v lvev taa,
Use of Well:
I Residential Public Supply Air /Cond/Heat.Pump Irrigation
primary
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought gpm # People Served __J� Est. of Daily Usage 3 hO gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
E,� i
heii SPstSe d vn ,i
q y
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 U +) V&DA k nd/S Lot No.
Water Well Contractor: Address:
Is Public Water Supply available t site? ................................. ............................... Yes No Se
Name of Public Water Supply: W' 14uVo °'� �n °l�s r {^ i' Di��' Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provide n separate sheet/plan.
% 1V
Date: I 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 (3 0) 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 driller certified by Putnam
County.
Date of Issue J� r %—� Z Permit Iss ' g Official:
Date of Expiration 3 ] - a Title:
Permit is Non- Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
,U 1�
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
_ AI'?T�TE' 'iIQ�`: �^ nL°A.c?'RG ^T .1�,, .W?�^'FR.,WF:LT _ .. f�I
PCHD PERMIT ICI
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
A/ X001 W 90 A, ,c/ rd9 4i-Q s 5"-f, - z S-
WELL OWNER
Name
% NIS5ERZOV
Mailing Address Private
0 r , L /(9 O3 9Public
SE OF WELL
- primary
2 - secondary
RESIDENTIAL
D BUSINESS
® INDUSTRIAL
0 PUBLIC.SUPPLY 0 AIR /COND /HEAT PUMP O ABANDONED
O FARM 0 TEST /OBSERVATION 0 OTHER (specify,
U INSTITUTIONAL O STAND -BY D
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED : /EST. OF DAILY USAGE 3d ®gal
97REPLACE EXISTING SUPPLY 0 TEST /OBSERVATION M ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED.
REASON-FOR
DRILLING
WELL TYPE
®DRILLED
O
DRIVEN
®DUG []GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES �0
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Ay14,p,&,mom
Lot No.
WATER WELL CONTRACTOR: Name .2 5.LC2 o Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: D�iLPtc��0 �0� , �°?T��W� /VIL /CITY P`J!id��
DISTANCE TO TO PROPERTY. FROM NEAREST WATER MAIN:
LOCATION SKETCH & OURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
(date) (signature)
1) Removal of. its to be witnessed by Put. Co. Health Dept. prior to w 4 constru t' on 2) well
be be staked by licensed surveyor 3) doub±ed cased we±i 4) altra tA.
be installed. 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
thirti� (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 dril g operations be contained on this
property and in suc a manner as not to degrade or of r ont urinate surface or groundwater.
Date of Issue: .6 �s 10
Date of Expiration 19� P it IssuiU Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
approved by specific waiver - refer to waiver for restrictions
"
'
k=u �� Waiver
°°~"Uver
ofOommunhySan�odon and Food pru�nUon from Bwqu|mementmwf Part 75 and ' ONYCBR
for Individual Household Swwa0e Treatment Systems
-
SW-11-97
Name of Applicant Sperling
-
No. Street City/Town State Zip
Address 21 Southern Road Putnam Valley NY 10579
Site Location 21 Southern Road Put
1. Reason why site does not meet 1ONYCRR Appendix 75-A(check appropriate box(es)):
| 0Separation distance cannot beachieved.
Excessive slope.
--
!
High groundwater.
� \Inadequate depth tu bedrock or impermeable layer.
�
Soil unsuitable.
2. Proposed design or conditions of waiver:
doubled cased. Removal of grey water pits to be witnessed by a representative
the.Health Department prior to the well construction.
'-_
increased risk of well or spring contamination.
increased risk of surface water contamination.
Expected design life of the system will be diminished.
Operation of sewage system is subject to mechanical problems.
----'---------'----'-'
Additional information attached
Construction pursuant to this waiver request should not pose any foreseeable health orenvironmental problems. hn accordance with
New York State Department of Health Administrative Rules and Regulations, Part 75.G(b).o waiver is hereby granted. This waiver
maybnnavnkudby1heissuingoMicio|forechangoinoondidonofo/whiohthimwo\verwongnonted.
4t_PAESffrTAf
---- --ORIGINAL ' Local Health Agency
~~- COPY 'App|�anoDoa�nProfessional
^ --T--7-----'�------------'
^
DOH'1326 (7Y92) (GEN45D)
Town of Putnam Valley
February 26, 1997
Kent Zook
12t, High Street
Putnam Valley, NY 10579
Dear Mr. Zook:
Re: Review by the Putnam County Department of Health of
proposed well for the following property:
Name.of Owner: Mortimer Sperling
Street Address: 21 Southern Road, wildwood Knolls
Tax Map Number: 62.15- 1- 25.(Town of Putnam Valley)
Please be advised that the owner of the above property has
app- Vutnam:County:Department of Health for a permit to
construct a well at the location shown on the attached site plan.
If, as a neighboring property owner, you have any questions,.
concerns or information which may influence- ,the. Department's
review of this application, you may call Mr. Robert'Morris of the
Department at 914 - 278 -6130, Extension 166.
notification, please
copy of this letter,
the enclosed stamped
Dr. the LepartmE.►i: that ypu nave received : -this
complete the acknowledgement below on one
and return that copy to me right away, using
envelope.
Sincerely,
Lenore A. Herbert
District Administrator
914 - 526 -3293
In duplicate
Received by_
Printed Name: 6. `
Property Tax'`Map' =No'." 62:15= 1=17.-&:18,;w.-
?65 Oscawana Lake Road ® Putnam Valley, New York 10579 . ®1. <914) •526. 3280 .
Town of Putnam Valley
February 26, 1997
Jane /James Ekizian
29 Sawmill Road
Putnam Valley, NY 10579
Dear Ekezian Family:
Re: Review by the Putnam County Department of Health of
proposed well for the following property:
Name.of Owner: Mortimer Sperling
Street Address: 21 Southern Road, Wildwood Knolls
Tax Map Number: 62.15 -1 -25 (Town of Putnam Valley)
Please be advised that the owner of the above property has
applied to the Putnam County Department of Health for a permit to
construct a well at the location shown on the attached site plan.
If, as neighboring property owners, you have any questions,
concerns or information which may influence the Department's
review of this application, you may call Mr. Robert Morris of the
Department at 914 - 278 -6130, Extension.166.
..To- let. us .document for the,_ Dep�ar -mgpI that -ycu _have recei-ved_. th;is__
__..__.
notification, please complete the acknowledgement below on one
copy of this letter, and return that copy to me right away, using
the enclosed stamped envelope.
Sincerely,
Lenore A. Herbert
District Administrator
914 - 526 -3293
In duplicate
Received by: 4we") (Signature)
Printed Name _ E (ZI tJ Date: J Z
Property Tax Map No. 62.15 -1 -22
265 Oscawana Lake Road • Putnam Valley, New York 10579. • (914) 526- 3280,.
.a..,,,.e ,a:.: , l
.. .. i,. �.. a-. .Y .. ♦_.tea .. •.. I, 4 :.I.� �. -T -.sO+r '..> �.y =
Town of Putnam Valley
February 26, 1997
Alice Walrath
72 Lakefront Road
Putnam Valley, NY 10579
Dear Mrs. Walrath:
Re: Review by the Putnam County Department of Health of
proposed well for the following property:
Name.of Owner: Mortimer Sperling
Street Address: 21 Southern Road, Wildwood Knolls
Tax Map Number: 62.15 -1 -25 (Town of Putnam Valley)
Please be advised that the owner of the above property has
applied to the Putnam County Department of Health fora permit to
construct a well at the location shown on the attached site plan.
If, as a neighboring property owner, you have any questions,
concerns or information which may influence the Department's
review of this application, you may call Mr. Robert Morris of the
Department at 914 - 278 -6130, Extension 166.
�3:. G?r t'rirr` `ilo art"mPn .�t:�ti !z� i... .).Q " °rer—e�•�jryr :th�c "-
notification, please complete the acknowledgement below on one
copy of this letter, and return that copy to me right away, using
the enclosed stamped envelope.
In duplicate
Received by:
Sincerely,
Lenore A. Herbert
District Administrator
914 - 526 -3293
Printed Name • '146-ce_ 1"' • Wk 1r4
Property Tax Map No. 62.15 -1 -26
(Signature)
a '
Date:
265 Oscawana Lake Itoad 9 Putnam Valley, New York 10579 w 9 (914) 526- 3280, -,�,,.
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March;;
Putnam County Departmer ,,Qf,° HA11q %
Mr. Robert Morris
4 Geneva Road, Route 312 ,r `
�rt
Brewster, New York 10509 r-
;J
Re: Waiver Request
Owners' Name: Mr. Sperling
21 Southern Road
Putnam Valley, N.Y. 10579
This letter is to request a waiver be granted in the matter of the above
referenced property for the purpose of drilling a well on private
property.
The application which was submitted to the Department of Health was
denied for the following reasons:
The separation distance between the proposed well location and the
existing
septic systems is approximately 97 feet to trench; 90 feet to leach
Pits.
A reduction in the required 100 foot separation distance is requested in
addition to a reduction in SSDS expansion area.
Please take into consideration that this variance request is being
submitted along with several others in the Wildwood Knolls
Improvement District. This District is attempting to discontinue it's
seasonal water system which has become antiquated and a financial
burden to the entire district.
I
7
Town of Putnam Valley
February 26, 1997
Ginger /Glenn Lefurgy
70 Mill Road
Putnam Valley, NY 10579
Dear Ginger /Glenn:
Re: Review by the Putnam County Department of Health of
proposed weii for the following property:
Name.of Owner: Mortimer Sperling
Street Address: 21 Southern Road, Wildwood Knolls '
Tax Map Number: 62.15 -1 -25 (Town of Putnam Valley)
Please be advised that the owner of the above property has
applied to the Putnam County Department of Health for a permit to
Construct a well at the location shown on the attached site plan.
If, as neighboring property owners, you have any questions,
concerns or information which may influence the Department's
review of this application, you may call Mr. Robert Morris of the
Department at 914 - 278 - 6130, Extension 166.
_us ..document four ---bt . Department that you _ have. recei,��A�j this
s . . .
notification, please complete the acknowledgement below on one
copy of this letter, and return that copy to me right away, using
the enclosed stamped envelope.
Sincerely,
Lenore A. Herbert
District Administrator
914 - 526 -3293
In duplicate
C
Received by,-" ` 41.l;r . (Signature)
Printed Name: %�r?v'i� LEA . �T_lt Date:
Property Tax Map No. 62.15 -1 -40
265 Oscawana Lake Road • Putnam Valley, New York 10579u•u,(914),526- 3280„
Town of Putnam Valley
February 26, 1997
Phyllis /David Posner
One Rose Tree Terrace
Ridgefield, NJ 07657
Dear Mr. and Mrs. Posner:
Re: Review by the Putnam County Department of Health of
proposed well for the following property:
Name of Owner: Mortimer Sperling
Street Address: 21 Southern Road, Wildwood Knolls
Tax Map Number: 62.15- 1- 25,(Town of Putnam Valley)
Please be advised that the owner of the above property has
applied to the Putnam County Department of Health for a permit to
construct a well at the location shown on the attached site plan.
If, as neighboring property owners, you have any questions,
concerns or information which may influence the Department's
review of this application, you may call Mr. Robert Morris of the
Department at 914 - 278 -6130, Extension 166.
To. et us document for.the Department that you have received -this
notif cetiori', please'complete the acknowledgement below on one
copy of this letter, and return that copy to me right away, using
the enclosed stamped envelope.
Sincerely,
Lenore A. Herbert
District Administrator
914 - 526 -3293
In duplicate
Received by:
(Signature)
Printed Name:
// }����iC'
Date:
Property Tax Map No. 62.15 -1 -19
265 ®scawana Lake Road e _Putnam Valley, New York 10579 ® „(914) 526 - 3280,,,,,;,,,; ,�
Applicant:
Notification Letters Sent To:
Mr. Mortimer Sperling
21 Southern Road
Putnam Valley, N.Y. 10579
Kent Zook
22 High Street
Putnam Valley, N.Y. 10579
Jane /James Ekizian
29 Sawmill Road
Putnam Valley, N.Y. 10579
Phyllis /David'Posner
One Rose Tree Terrace
Ridgefield, N.J. 07657
Ginger /Glenn Lefurgy
70 Mill Road
Putnam Valley, N.Y. 10579
Alice Walrath
72 Lakefront Road
Putnam Valley, N.Y. 10579
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
Mr. Sperling
21 Suthern Road
Putnam Valley, NY 10579
Dear Mr. Sperling:
BRUCE R. FOLEY, R.S.
Ac wq Public Health Director
February 28, 1995
Re: Proposed well
Review of plans and other supporting documents submitted at this time relative to
the above captioned proposed well has been completed. Comments are offered as
follows:
1. The separation distances between the proposed well location and the existing
septic systems is approximately 97 feet to a trench system and 90 feet to
leaching pits,
100 feet is required by today's standards to a trench system. 150 feet is
required by today's standards to leaching pits.
In light of the foregoing, your application is hereby denied.
For , the reasoris- outlined above your ' appl i cation has" been d6ni ed Arid- as "w if to " ai `i
denials it is within your rights to request a variance from the Putnam County
Board of Health. Guidelines for the variance procedure have been enclosed.
This Department has been in correspondence with Ms. Marianne DiSantis, District
Administrator, Town of Putnam Valley. It has been the Putnam County Health
Department's position that all thirteen homes reported as currently being
supplied by the Wildwood Knolls water service be considered for variances at the
same time. The intention being that, if permittable, all thirteen homes would be
removed from the water service. At this time it appears complete applications
have been submitted for 10 of the 13 homes on the water system. At the request
of Jim Gordon, Putnam County Legislator, determinations (denials or approvals)
are being considered for all completed applications.
Please be advised' that the Board of Health may require that all thirteen
proposals be considered at one time.
Very` truly yours,
Robert Morris, P. E.
Public Health Engineer
RM/jp
:a
_ L. ♦ 1 h
No
FPL;CE R. FOLEY. R.S:
t
c Ar ;M Ekfth �I•QL 0•—
,F.fl�'�.:� '.tJiax�:�/li� /..4`..:c.:,4,� _ ,....r,,.ai� S • _ ..,.. -r.. ..a.:,. .. ..,_. ,. �.. .., _
r,.L``'}i %r'?. .'��i yx�•^.p +l .1�5r �.;;� It.. "l :c 3 Jr .m .zr� x 1 �+•s;.*s `}u�t..ak h.i
leaching` pits , & ,
100 = feet: �s requit red
by standards tb!a trench system. 150 feet is
required by today -s standards to; leaching pits _ ,r
g < u f
z
In.11ight. of the. foregoing, your application is hereby_ denied.
- -� -For -- the -- reasons_ out fined_ above_ your application has, been denied and as with all
denials .it is within your rights to. request a variance from the Putnam-- County
Board of Health. Guidelines for the variance procedure have been enclosed:.
This Department has been in correspondence_ with Ms. Marianne DiSantis, District``:
Administrator, Town of Putnam Valley. It has been the Putnam County Health
Department's position that all thirteen homes reported as currently being
suppl- ied= by=th4ft-WiIdwood- Kno -lIs:_ water. seryice_be_ Cons idered_for variances_ at the
same time. The intention being that, ifpermittable, all thirteen homes would
removed from the water service. At this time it appears complete applications;- ".
have been submitted for 10 of the 13 homes on the water system. At the request.
of Jim Gordon, Putnam County Legislator, determinations (denials or approvals).
are being considered for all completed applications.
Please be advised that the Board of Health may require that all thirteen
proposals be considered at one time.
VZ,,/ ruly yours,
/u,
Robert Morris, R. E.
Public Health Engineer
'� RM /3p
1444 4 (2187) —•Text 12
',P•ROJECT I.D. NUMBER B1T.21 SECT R
.9
Appendix .0
-- _:....,.�.. • , ., -. .. :� _ . _ :.. _ �; .. _ „ .. .., ;.:�i�'in �-`' cnitti� rirtiiii�t�fi�'ueTiiy�HetrTetlii ,. .... .� ... .. .
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1. APPLICANT /SPONSOR
2. PROJECT NAME
erlin
Wildwood Knolls
3. PROJECT LOCATION:
Municipality PUtnam Valley County Putnam
4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide. map)
21 Southern Road, Putnam Valley
TM #62.15 -1 -25
5. IS PROPOSED ACTION:
n
[]New El Expansion Modification/alteration
6. DESCRIBE PROJECT BRIEFLY:
Construction of a water well
Removal of gray water pits
7. AMOUNT OF LAVD AFFECTED:
1/4 1/4
Initially acres Ultimately acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
❑ Yes ❑ No It No, describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
R1 Residential ❑ Industrial ❑ Commercial Agriculture ❑ Park/Fore3t/Open space [10 ther
Describe: :
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL)?
❑ Yes ® No If yes, list agency(s) and permlt/approvals
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY -VALID PERMIT OR APPROVAL?
❑ Yes Mo It yes, list agency name and permll/approval
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION?
❑ Yes n No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant /sponsor name: Date:
Signature:
If the action Is In the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
1
i.
�I
PART II— ENVIRONMENTAL ASSESSMENT (To ..be completed by agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. ` r
❑ Yes No
=. NILE iii 4 REEC6Vr 63dRbINhi E&`kEVii- EW -AS`r ROVIDEG FOR UNL19TEd ANIONS IN 6'NYCRR, PART 617.6? If No, a negative declaration
may be superseded by another Involved agency.
❑ Yes c5rvo
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible)
Ct. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erosion, drainage or flooding problems? Explain briefly..
No
C2. Aesthetic, agricultural, archaeological, historic, or other natural. or cultural resources; or community or neighborhood character? Explain briefly:
\I-g>46 (OJAIID
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain.briefly
C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly.
C6. Long term, short term, cumulative, or other effects not identified In C1-05? Explain briefly.
C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly.
D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑ Yes ()'�o If Yes, explain briefly
PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect Identified above, determine whether It Is substantial, large, Important or otherwise significant.
Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural);. (b) probability of occurring; (c) duration; (d)
Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed.
❑ Check this box if you have Identified one or more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL EAF and /or prepare a"positive declaration.
Check this box If you have determined, based on the Information and analysis above and any supporting
documentation, that the proposed action WILL NOT result In any significant adverse environmental impacts
AND provide on attachments as necessary, the reasons supporting this determination:
TOWAM 02J
kaa6 V or 44"LV4
Officer in Lea Agency Title of Responsi e O icer
:er in Lead Agency % L 2 Signature of Preparer (It different from responsible officer)
ate