HomeMy WebLinkAbout31235_1%EA-d 901,
WLLiL Uk)r1ri.L11UL,4 r._r!rUr,1 Office Use Only
DEPARTMENT OF HEALTH
. (�I�Vfees
PUTNAM COUNTY DEPARTMENT OF HEALTH
STREET RESS: WNIVILLA I I Y TAx GRID NUMBER:
WELL LOCATION A
WELL OWNER
NAME: ADORE is:
AN
9-P81VATE
❑ PUBLIC
USE OF WELL'
1 - primary
2 - secondary
8-RESIDENTIAL AD PUBLIC SUPPL 0 AIR /COND. /HEAT PUMP 0 ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY 0
AMOUNT OF USE
YIELD SOUGHT gpm./NO. PEOPLE SERVED _/ EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
.[]REPLACE EXISTING SUPPLY []TEST/OBSERVATION []ADDITIONAL SUPPLY
[aNEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH a D 6 ft. I
STATIC WATER LEVEL — - ft.
MEASURED
DRILLING
EQUIPMENT
I!T'ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED (PEN END CASING ❑ OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH tL
MATERIALS: G-STEEL ❑ PLASTIC ❑ OTHER
LENGTH BELOW GRADE
JOINTS: ❑ WELDED 91-THREADED ❑ OTHER
—DIAMETER in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE INNER
WEIGHT
PER FOOT Ib./ft.
DRIVE SHOE DYES 0,NO
I LINER: DYES 9NO
SCREEN
DIAMETER (in)
SLOT SIZE
LENGTH (it)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
SE LINU
OJES -a No—
`j-
GRAVEL PACK
0 YES
❑ No
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH —ft.
BOTTOM
DEPTH — It.
WELL YIELD TEST If detailed pumping
METHOD: 0 PUMPED tests were done is in-
DeCOMPRESSED AIR formation attached?
❑ BAILED ❑ OTHER 0 YES 0 NO
It more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
Well
Oia-
Mle,
in
FORMATION DESCRIPTION
CODE
ft.
I ft.
WELL DEPTH
it,
DURATION
hr. min.
DRAWDOWN
ft.
YIELD
9pm.
d
Sur Lanlace
er
WATER 0 CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? ❑ YES 0 NO
STORAGE TANK: TYPE 190
CAPACITY GAT,.
WELL DRILLER NAME DATE
ADORES� Alm-r� 0 S&Q6
• 0 11,r)r fo -T�-f
V
PUMP INFORMATION
TYPE _(" W.4"4 -, 1-t CAPACITY
MAKER atu.4. dIp.5 DEPTH I iG_
[001E VOLTAGE )-W HP
J/ 0y
,YML Environmental
Services
. _ 321.Kear.S.treet, Yorktown. Flei ts:.l�iY. ?,
ELAP #10323 ^x(914) 245 -2800
REAL ENTERPRISES, LTD.
23 FERRIS LANE
BEDFORD, NY 10506
COLD BY MICHAEL LIPSON
NOTES
X
RESULTS OF
ANALYTE
RESULT UNITS
pH Ji
ALKALINITY
S.U.
mg/L
PHOSPHOROUS
AMMONIA
mg/L
mg/L
SILVER
CALCIUM
mg/L
mg/L
SODIUM
CHLORIDE
mg/L
mg/L
SULFATE
COLOR
mg/L
Units
SULFIDE
CONDUCTIVITY
mg/L
umhos /cm
SULFITE
COPPER
mg/L
n-g/L
TURBIDITY
CORROSIVITY
NTU
LSI
�"
� ut;Ti✓kG�iv""T5_ ., ._ �,•_
....:,�.'�'o`r:�
/L -_ �-
__ - -
FLUORIDE
rrg/L
HARDNESS
mg/L
IRON
mg/L
LEAD
mg/L
SPC
MANGANESE
per 1.0 mL
mg/L
TOTAL COLIFORM
MERCURY
per *100 mL
mg/L
FECAL COLIFORM
NITRATE
per 100 mL
mg/L
E. COLI
NITRITE
per 100 mL
n-g/L
FECAL STREP.
ODOR
per 100 mL
TON
LAB NUMBER 32. � i0 078- 1.'�
I DATE /TIME TAKEN I - , _ - , _ _ _ _ . _ ... I
DATE REPORTED I FFR f1 R ian'
SAMPLING KITCHEN TAP: #g ALBERT LANE
SITE UTNAM VALLEY, NY
For Lab Use Only
_A Potable — HNO3 — pH LT 2 _�( <4C
Nonpotable — NaOH — pH GT 9 — <20 >4C
_ HCl Na2SO3 — >20C
s STAT! H2SO4 — ZnOAc
r
eOLoll. NrETI Il us .
X
RESULTS OF
ANALYTE RESULT UNITS
pH Ji
S.U.
PHOSPHOROUS
mg/L
SILVER
mg/L
SODIUM
mg/L
SULFATE
mg/L
SULFIDE
mg/L
SULFITE
mg/L
TURBIDITY
NTU
SPC
per 1.0 mL
TOTAL COLIFORM
per *100 mL
FECAL COLIFORM
per 100 mL
E. COLI
per 100 mL
FECAL STREP.
per 100 mL
These results indicate that the water sampl [WA [WAS NOT] [NA] of a satisfactory sanitary quality according to
the New York State Sanitary Code, for the rame rs tested, at the time of sample collection.
These results indicate that the water sample [WAS] [WAS NOT eetilh satisfactory chemical quality according to
the New York State Sanitary Code, for the parameters tested, at sample collection.
NA = Not Applicable N = Not Present (Negative)
SUBMITTED BY: Present (Positive) SA = See Attachment(s)
' = Also done because Total Coliform was present
Albert H. Padovani, M.T. (ASCP) TNTC = Too Numerous To Count
Director > = CT = Greater Than < = LT = Less Than
PUTNAM COUMfY DEPARTMENT OF HEALTH
,c, a:• � ..t,. .,.• ;:. ^ ,TFCT(��'f- n% "v (r`t A ari.$,: '� � - �� ''Sr i �' .:.. - >..e ..�.,_ , .... .—
�......•.�_.... .. .. .. �.•:: -_r. ..� a�:d�.'nr..:a.�:....e _._ �F� � ,.��a• .. < .�_ : ��.._.'i .�IC,C.Su ::... �:,:�; ii ...e. pis::,.
�1. F-rwLvv °!
Owner or Purchaser of Building Section Block Lot
Icy"f.
Buildi ng Constructed by
/a L /
Location - Street
Municipality
ID4
Building Type
Subdivision
Subdivision Lot #
GUARANTEE 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
�er`c iiYC dC� of` Cz�riSLiuci: otr loin iiiaice f6r -the 5ewaye-uispbsai 5ystEi 6i"
airy
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 Division of Environinental 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 th /��1/+? g utilizing
the system.
Dated this day of 19 Signature7` -ice /✓
Title
General Co ctor (Owner) Signature
Co 'ration Name (if Corp.)
Corporation Name (if Corp.) vZ
/ Address
Address
rev. 9/85
mk
PUTNAM COUNTY DEPARTMENT OF HEALTH
Dlvlsbn of Envbonmental -,I -t Services Ciirmol N.Y 1051? Bm to Provide Permit N
En eer
` oa CERTIFICATE.OF, CO CE
ON UCTION PEiM FOR SEWAGE DISPOSAL SYSTEM permit . M s
��7n! Rte• vaG���'
% l�ij t7 f"i"pP %� +�' ! RiQ PP v!� �►' '.+ i a Tewr 7 er PMmae
Sabdivbdon Neute SCI 0 A Q //0, Sabd. Lot N Ta: Map Block . " Lot
Renew Revision ❑
Owner /Applicant Name �� Az, . F
Date' of Previons Approval
Mdung Adttreea - f 't2rr(S:�i ,P- Town Zip
Othee Reoalremente_* /1 r g (iV!c,�:.ir 1131 1),� ,iy.� cK
I represent ttiat'I am wholly and ^completely resDOniibleyfor the des,gn and loestIon of the proposetl systems) "1) that 4he; separate sewage disposal system
Above described:will be constructed as'shown on'the'approved amenCrri to here'to and inl accordance witf 'the`standardi, ruies an regu a :ons o e u nam
County :Depa'rtm
d tent of Health, and that on completion thereof i Certaticate '•of Construction Compliance" satisfactory to the
Commissloner,of Healthwlll
be submitted :the Department,: and a written 'juirantie'will'be;iurnished :the owner,. his' successors; heirs'or a signs by'the builder, that said builder Will
place in good operating condition any part of said sewage disposal system duffing the period of two (2) years Immediately tollowirq thedats of the isw-
ance'of the ipproval of the Certificate of" Construction Cornplianie oC`tfie ocyin`- ystem or any repairs t veto; 2) th the drilled well described above
y 11 will be installe0 in rdanee with the;, a s, rulregu a ions Of ,the Putnam
will be located as shown on the approved plan and that said we r
Count Depe me t of Health:
Date �� Signed P.E. R.A. -
ACtlre r License No
APPROVED FOR'CONSTRUCTION:This appr9vii4xpires two years -,from fire date issued' unless construction -of the building has been undertaken and is
revocable for cause or may be amended or modified when by, the Commissioner -of Health. Any change or'elteration of construction
requires a w permit. Approved for, disposal of domestic sarii4iy:wwage, c/!! ,pn a water. supply 'only.
1187 Date Z S�i / �-' BY �. /�
Title ...�.�. ._�_w.... _..
_ A
' PUINAM CCXJNT Z DEPART OF HEALTH
DIVISION OF EiVn1UZM?ML HEALTH SERVICES
- APPENDIX I
lU li i`I L1F�11 Siix c;l'- SU8S701FA E SF�nTA, 'DISPOSAL SYS +I FILE VD.
Address
r C,,
lc< —Ate at (Street) a Se=.'. Block Lot
(indicate nearest cross street)
Minicipality p�u �i, a r� ! L Watershed
ate o
f
ROLSO: P�COLAffIC N ZI ST DATA REQUIRED TO BE SUE II= WrIH APPLICATIONS
L.
Pre- Soaking 21d. Date of Percolation Test z ,n
SuffQ V /�lON LOT �•�
NU6' 7R a=
TIlKE
PE CGLAmw
PER00LATI0
Run
Elapse
Depth to
Water From
beater Level
No.
Time
Ground
Surface
in Inches
Soil Rate
Start -Stop
Min.
Start
Stop
Drop In
Min/In Drop
Inches
Inches
Inches
1 /D 7 A/)
_1.13
3
'
2/0
3 LO
4
R
3 / Z3 3 D =
4
E
1
K
3
4
5
ES: 1. Tests to be repeated* at same depth until approxmate?y equal. soil rates
are obtained at each percolation test hole. All data to* be snit(
for review.
2. Ce_ t+h a asurewnts to be m =.'e fran " ^p of hr1A.
PC -1
1PiJTNAM COUNTY DEPARTMENT OF HEALTH
.:..DISPOmot -7 -+
Apl1CAl'ON yFOi�' APPROVAL` dF F'LANS FOR `A WASTEWATER SAL SYSTEM�
. . -- .' _ _ .1 . Y ... .. fib, 1 •. tC< Sa �t,
1. Name and Addr=ess of Applicant: %e /i,G 1°RDlsj6W:L/ A li!/Z"
2. Name of Project �J'JV %Otot /T 3. Location T/V /C: 1�G7N% LJGcff'
4. Project Engineer: D4,7,-c/ c% a6a 4 n.k 5. Address: •g,.Et�';. -;
License=Number: Phone: ed. r,)
6. Type of Pro.iect:
Private /Residential Food Service Commercial
Apartments Institutional Mobile Home Park
Office Building Realty Subdivision Other,(specify)
7. Is this project subject to State Environmental Quality Review (SEQR)? -
Type- Status - (Check One.) Type I.. Exempt
Type II. Unlisted K
8. Is a Draft Environmental Impact Statement (DEIS) required? ............. A10
9. Has DEIS been completed and found acceptable by.Lead Agency?... :..
10. VName' of Lead Agency-
ia
! i t t! 1s prc; eat �^ ?t' area ur1UeF iris cone o i -o p.ca:' lfi�lriitl� �Qt'in ;
or other Officials, "ordinances?
12. If so, "have-plans been submittedyto such authorities? .................. � 9fr
13. Has y approval been granted by such authorities�'�*' Date Granted
4 Type of Sewage Disposal System .. t -n� G nd Wa
E ,s Surface Wa er roue tars s"
i
._ . -..__ ..; :_-__ _._ - :. -�>+- s-- tt 2 -r---- -ice-•* ;•-� ...3 ;�.
5. If surface water discharge, what is the stream class designation ?........
6. Waters index number (surface) -�
7
xt -�. ct �t `T•r1 �'""+C ��.'�� t�.:t
%a .z�• x 3 ii r
7. project located near ,a public water supply system
8.'If yes, name of.water supply Distance to water supply
t....t sv , ..r ^., -•, ttA. ,. -y ? "r d �� �. !rc` t� t t. �11.
9 Is pro 3ect site near a public sewage collection or disposal systems
! .' i r rt; L rt i "� t j ... s At•S 2 *. r.. „a �. , n � �
kA
, 2 we of sewage system =° " -
Distance to: sewage system 2 y
Date 'observed �_^° °2 H' l
""�" "" 3 Name of eath Inspector
1. y?'
rfi; ' .+ n t k t FEZ s uhci 4R "`r i t -i
GYM 2 2 t i.t t.. t t ._fit u •-x+• jc - '
I Project design flow (gallons per day)
j,
ON
Y .( 'r u. .x.51} j 1N {. - ,�I C S1 L. .h .•+tkv -.� 4i2;
i
:r
25. Is State Pollutant 0,1! a-,,ha-: r
t i on . System
Perm-it required ?.
28. Wetland ID Number--.'.' ..........
29. Is Wetland Permit
Has application been made to Town or Local DEC Office? .................. .
30. Does project.require a DEC Stream Disturbance Permit? ...................
31. Is or was project site used for agricultural activity involving application
of pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application'or industriail activity? ........ YES or NO
32. Is project located within 1,006_ feet.of eXisten . ce of abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential known source of contamination? ...............YES or NO -No
DESCRIBE:
32: -Is there a local master plan or file with the Town- or Village?
'
Are community water,.-sewer-,-facilities -planned to-be developed within -15 ypa-rs.-
r
....35,,,,,jkr-e-p.ny-,-sewagp-.d,isposai .;.7.
Tax -Map Number ......... o
36. Ta ..... .........................
37. Approved Plans are to be returned to: ....... Applicant YEng"in'ee'r
If the application is sign ed by a person other than the applicant shown in Item 1, the,
application "Miuiist be accompanied by a- Letter" -of Authorization.'- , -Fallure to comply "with this
be grounds for submission ..,
Drovision may the rejecti*on*-.6f any'-
I hereby affirm, under penalty of perjury, that information p'i6vdded 'on
form is -true to the best of my knowledge and belief. ' False statements made
l, ,
id . 4� 0
herein are punishable as a Class A M iid pursuant to Sec ion 2 0
J
the Pena I Law.
y.
;IGNATURES & OFFICIAL TITLES:
Z,�
SAILING ADDRESS YM :
TEST PIT DATA REQUIRID TO BE S'JEMITTED WITS APP=C.ATION
DESCRIPTION OF SOILS E CUNiE ED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. 2 HOLE NO.
. .. V.L. '
�oQ r a r c rta yra r L
ion ^i
2'
3' /tiara frn
4' S'r
Gon�a�i�d 1po�,
5'
6'
7
8'
9'
10'
11'
12'
13'
14'
M V INDICATE LEVEL AT WHICH GROUNCMATF.R :IS ENMUNMM
INDICATE LF.UEL TO WHICH WATER LEVEL RISES. AFTER BEING ENM[jM =
DEEP HOLE OBSERVATIONS MADE BY: ,d °4 Loh 1r DATE:
DESK. --q
Soil Rate Used '/v Min/l" Drop: S.D. Usable Area Provided
No. of Bedroans Septic Tank Capacity gals .• Type
Absorption Area Provided By LI.F.'x 24" width trench
Other 3 112- l� 0 ti � 4 r/ / -7 d t
Nameyt �. �i o n ��l Signature /zot, �
Address gr ec, 4-C n ; �� SEAL
0
THIS SPACE FOR USE BY HEALTH DEPAR.._Nr ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT 0
WELL LOCATION
Street Address
dod e J ��' ' G 0y;r
Town/Village/City
y-j iv l�i9GG
Tax Grid Number
L �7
WELL OWNER
Name Mailin
L ��1 /fi %�
Address
ei� >I �°`�I�.
rivate
Public
E OF WELL
primary
2 - secondary
RESIDENTIAL 0 PUBLIC SUPPLY Q AIR /COND /HEAT PUMP 0 ABANDONED
9BUSINESS O FARM O TEST /OBSERVATION 0 OTHER (specify
® INDUSTRIAL 13INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT_ gpm /#
PEOPLE SERVED /EST. OF DAILY USAGE6db gal
REASON FOR
DRILLING
® REPLACE EXISTING SUPPLY
NEW SUPPLY NEW DWELLING
0 TEST/ OBSERVATION
® DEEPEN EXISTING WELL
O: ADDITIONAL SUPPLY
DETAILED
REASON FOR
DRILLING
- " e/ ! e4/ 0ji,ri
yjC
WELL TYPE
WDRILLED
DRIVEN
®DUG
®GRAVEL<
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
TELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: f'Ciet
Lot No.
HATER WELL CONTRACTOR: Name ��� ( Address : grew f /er
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
AlniE'Tv IIAi "►v.a_��f..%f
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON SEPARATE SHEET
(date) (signature
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
Department attached to this permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
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 drilling operations be contained on this
property and in such a manner as not to �degrade or otherwise contaminate surface or groundwater.
Date of Issue:
Date of Expiration 19 j Permit Issuing Official
Permit is Non = Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
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PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
APPEPIDIX L
AFFIDAVIT - CORPORATE. -OWNER APPLICATION*
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
represent that I am an officer or employee of the corporation and am authorized
to act for te-V- / e&17r,-
(Name of orporation)
having offices at 2,3 2E'�'Y'i.1' C
Whose officers are:
President:
Vice — President:
Name and Address
Name and Address
Secretary •
.. (N rye. :and Addz-es-5-i
Treasurer:
4t-�r
(Name and Address
Qom'
Ir
and that I am and will be individually responsible for any and all acts of the
corporation with respect to the approval requested and all subseq relating
thereto.
Sworn to before me this I� day
of 19j
o t a Public !
ELIZABETH H. REGENSBURG
Notar•! Ffuthlic, Stitle of New York
Qualified in Putnam County
ComiT1iSSion Expires Nom•
8/84
Signed:
Title:
t'4y" v
v
K)
ry
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