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BOX 31
Lei e
i ��
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
10"CGN.SrTRUC`I' - A .1 -A ER- WILL
PCHD PERMIT #
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
r12_ P L F AS P%NT CAD, L ME me-K-3 K%L.L
WELL OWNER
Name Mailing Address
C)LSEN tj LARRY Pa SOX Igg LIKE PKSKL M, IoS32
)(Private
OPublic
USE OF WELL
lU- primary
2- secondary
11RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
0 BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL M INSTITUTIONAL O STAND -BY
0 ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE��ga1
E3 REPLACE EXISTING SUPPLY O TEST/ OBSERVATION Q ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
DUG
GRAVEL
C1
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:-
NO Lot No.
WATER WELL CONTRACTOR: Name A' VEFSON CTo lam tom" Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _')<_NO (SVMMEjZS (ON lsy
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY LK. PKSK"
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
RON SEPARATE SHEET ,
(date) "gnature)
MU S1 "Vrr w ton SwARRTM4 frRom 6Ni 5, sllsS
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
thirt3• (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 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: 19
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
v PETER C. ALEXANDERSON
County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
Sept. 29, 1987
L. Olsen &
B. Santa- Coioma
Box 198
72 Pleasant Road
Lake Peeksk-ill, NY 10537
Re: l4el l Permit #
Dear Sir:
JOHN SIMMONS. M.D.
Deputy Commissioner
W- 107 -87
Forwarded herewith is a permit to drill a wel.l..on.:the above captioned prop-
erty for potable purposes.
You will note that the permit is to drill the well only and is issued for one
year.
Approval'to place the well in service will be granted upon receipt of the
following:
Completi "on R'epor't for "The"'new "well': ' "`°
2. Result of Bacteriological Analysis.
3. Information as to the depth of the old well.
If you have any questions, please contact me at 225 -0310, ext. 304.
Very truly y rs -,
414-
�ohh Karel l , Jr. , P.E.
Director
Environmental Health Services
JK: cj
110 OLD ROUTE SIX CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
A
DEPARTMENT -OF ITEALTH
Division., of Environmental Realth'Servides
COUNTY CENTER,- CARMEL, N.Y. 10512 (914) 225-3641-
S�
q"IAPPLICATION TO'CONSTRUCT A WATER WELL
-C
P D V
If
IS ;WELL SITE. SUBJECT: T,Oi.XLOODIN9�_ -YES, M .NO"'
IF WELL IS LOCATED;.'JN..,,'k, REALTY, SUBDIVISION,` - NAME OF SUBDIVISION:-—
41 Q
Lk* No.
r.
WATER WELL CONTRACTOR:. 4 Name D) IQ Address:
IS PUBLIC WATER SUPPLY AVAILABLE, TO, SITE: YES V N6,
c' V,
NAME OF PUBLIC WATER SUPPLY: TOWN/Vi L/CITY".%
DISTANCE TO.-PROPERii: FROM NEARE ST_ WATER MAIN:
'.7 7
'
LOCATION SKETj&.&;SOURCES OF CONTAMINATION! PROVIDED N, 41
3 N-.,REAR OF THIS','APPLICATI614, ON S�P
,11ARATE: -SH' T
(date) (signature)
'IT Ali
I'�t
J'.
VO,7,CONSTRUCT`A WATER. WELL.
z,
This pe rmi t',,, to construct o ne,,,water, we 11 as `se t forth,,-aboVe is granted under the
6,� San'i tAry Code, ah
Provis, oln§ Ebf;,,1S,qbpart,`,5-2,;, d'
_. 1 1 0;
"de&'that':Wjr x tion
thih,�,� .t �'(�O) 'days' -'6f.,thd d6m�..Tetj� ,,qfmater well .construction, P�ov) y
the�.applicant ils.h�j
�-,�,YA . 1 "P
mp'-the well
'd' with we� A `4
Disinfect the" ell ccor ance,-,i the requirements ,of the Putham,
1'66ty' .He'alth,,`66' p aftnie h t '.a tt o'° ;`i h i §
pr
�bn, a�ftrmlprov
We 11.
3 S&ntt.`:� i?'
Health _�,Depaftmqn
"y
Date of
'sU in g f O fr
*!*I";", 51W
Date,of Expiration* Is
19',f
VMite cpj5yt`:* H. D '
,.�Xile
Permilt'is' Nbn= Tria6sferrabie::
Yellow cvpyrt, Inspedtor.
Pink, Copy er,
�.2/8T
Orange -;
;Mr: Iy cc)pyWell.Drill er
Sti Address Tox4n/Village/City Grid, '.Number'..'.
f, .get
WELL LOCATION
r`r 7,
t
1`0 �,61 v Ka !Fig K"S -;'i LL
WELL-,, OWNER'�`�'4� -
1,M6, .Nape mail in4. Address -�
41";` ",
. . ,
_I A,
1 ,
, !� . PS� z;. Public VIC=
S OF.... WELL
P!, E
�',,�.i.�'.`GrKESIDENTIAV, E] PUBLIC SUPPLY (JAIR/COND/H EAT PUMP D ABANDONiV,".��',,"" 1'
p rimary,.�.!
BUSINESS TEST/OBSERVATTbN�. D. OTHER
ESS_ spipcif Y:
2 secondary
k. j
INDUSTRI AL INSTITUTIO NAL IVO
N L C STAND-BY�!
'AMOUNT OF
SOUGHT 9 POPLE SERV ED /EST'.: OF DAILY USAGE''
REASON.-,'FOR
`..SUPPLY %�,.,,PPROVizE ADDITIONAL 'SUPPLY ,.,�,,,'ClTEP hkd T)'OBSERVATIONH
1°ADRILLINGG
_w
REPLA EEXI STING,'. SU PA E EPEN'EXISTING WELL
.DETAILED.
REASON VOR
DRILLING
WELL TYPE'-`..-:
DRILLED
DRIVEN DDUG [3 GRAVEL 0 OTH
If
IS ;WELL SITE. SUBJECT: T,Oi.XLOODIN9�_ -YES, M .NO"'
IF WELL IS LOCATED;.'JN..,,'k, REALTY, SUBDIVISION,` - NAME OF SUBDIVISION:-—
41 Q
Lk* No.
r.
WATER WELL CONTRACTOR:. 4 Name D) IQ Address:
IS PUBLIC WATER SUPPLY AVAILABLE, TO, SITE: YES V N6,
c' V,
NAME OF PUBLIC WATER SUPPLY: TOWN/Vi L/CITY".%
DISTANCE TO.-PROPERii: FROM NEARE ST_ WATER MAIN:
'.7 7
'
LOCATION SKETj&.&;SOURCES OF CONTAMINATION! PROVIDED N, 41
3 N-.,REAR OF THIS','APPLICATI614, ON S�P
,11ARATE: -SH' T
(date) (signature)
'IT Ali
I'�t
J'.
VO,7,CONSTRUCT`A WATER. WELL.
z,
This pe rmi t',,, to construct o ne,,,water, we 11 as `se t forth,,-aboVe is granted under the
6,� San'i tAry Code, ah
Provis, oln§ Ebf;,,1S,qbpart,`,5-2,;, d'
_. 1 1 0;
"de&'that':Wjr x tion
thih,�,� .t �'(�O) 'days' -'6f.,thd d6m�..Tetj� ,,qfmater well .construction, P�ov) y
the�.applicant ils.h�j
�-,�,YA . 1 "P
mp'-the well
'd' with we� A `4
Disinfect the" ell ccor ance,-,i the requirements ,of the Putham,
1'66ty' .He'alth,,`66' p aftnie h t '.a tt o'° ;`i h i §
pr
�bn, a�ftrmlprov
We 11.
3 S&ntt.`:� i?'
Health _�,Depaftmqn
"y
Date of
'sU in g f O fr
*!*I";", 51W
Date,of Expiration* Is
19',f
VMite cpj5yt`:* H. D '
,.�Xile
Permilt'is' Nbn= Tria6sferrabie::
Yellow cvpyrt, Inspedtor.
Pink, Copy er,
�.2/8T
Orange -;
;Mr: Iy cc)pyWell.Drill er
WFL..L. Loc.Pr rION
198.
� us3 ri
y�LOT
IZ a *2� o
Alt 0+ *-?.4 l
P°'
o
v °Al
t"
(Nod
d
y�LOT
IZ a *2� o
Alt 0+ *-?.4 l
MARVIN O'DELL
Inspector
TOWN OF, PUTNAM VALLEY
BUILDING, ZONING, AND SANITARY. DEPARTMENT
August 27, 1987
Robert Morris
Dept. of Erie. Health
110 Old Route 6 �
Carmel, N.Y. 10512
PUTNAM VALLEY, N.Y,
(914) 626 2377
Re: Olsen /Santa - Coloma - TM #86 -2 -10
Pleasant Road - Lake Peekskill
- rr
r
r
Dear Mr. Morris:
The proposed well shown on sketch drawing submitted conforms
to the requirements of separation between any SSD system and,
therefore, would be approved by this Department for construction.
Upon completion, a copy of well drillers log and water analysis
report shall be submitted to the Building Department by the
owner before the well is put in service.
MO'D:es
Very truly yours,
MARVIN O'DELL
Building Inspector
z
PETER C. ALEXANDERSON
County Executive
,Ae
A_1t;0
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
L. Olsen and B. Santa - Coloma
Box 198, Pleasant Road
Lake Peekskill, NY 10566
Re:
Dear M/M Olsen and Santa - Coloma:
September 2, 1987
JOHN SIMMONS, M.D.
Deputy Commissioner
JOHN KARELL, Jr., P.E.
Director
Proposed well, Olsen and Santa - Coloma
Lake Peekskill
Review of plans and other supporting documents submitted at this
time relative to the above - captioned project has been completed.
Comments are offered as follows:
On September 1, 1987 a field inspection was conducted by this
writer for the above captioned proposed well. At that time it
was determined that the original proposed well location was not
acceptable due to_:a..kitchen.dry' well approximately 80 feet away on
an adjacent lot. This situation is easily resolved by relocating
..t -he -.well 100 -feet from the dry To` r_6mpl.ete' .the* _ap arovai-
process, the application to construct a water well must be signed
by the applicant, permit enclosed.
Attempts to reach you via telephone have been unsuccessful.
Very truly yours,
Gov 7�mo
Robert Morris
Environmental Health Technician
RM : amm
Enclosure
,,4/
,�
t�z
DEPARTMENT OF HEALTH
Division of Environmental Health Services
0 COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 42 _
+::ow.�ii.' "rµ•'oa���.JYl I.l1r171:•IJLV• °-`1 V 1+`U� _ V 1. Wtir�lt M1 - .�� =::_' -�• �. e- . .�. .. • ...���• p�j.+ :_.
PCHD PERMIT
WELL LOCATION
Street Addr
OX, lag AS ess ' Pa-s
Town/Village/City Tax
Grid Number
WELL OWNER
Name Mailing Address
Ld ��-- BENF3,S'/tiA�C.��„m�+►�. -- S�n'1E t3S
rivate
OPublic
USE OF WELL
10- primary
2- secondary
ffRESIDENTIAL
0 BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
❑ ABANDONED
O OTHER (specify
Q
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE. SERVED /EST. OF-DAILY USAGE gal
REASON FOR
DRILLING
NEW SUPPLY OPROVIDE ADDITIONAL SUPPLY
13REPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
OTEST /OBSERVATION '
DETAILED
REASON FOR
DRILLING
WELL TYPE
tz.jDRILLED
DRIVEN ODUG
GRAVEL
Q
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED.IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
ni Lot No.
WATER WELL CONTRACTOR: Nam;"" N 6. I..- L, Address:C. PagKSk<11..L
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _NO C S� � '1
NAME OF PUBLIC WATER SUPPLY: - �.6 a� TOWN /VIL /CITY
- ril.,I..XCE -PTO AUPER'! =�
LOCATION SKET H & SOURCES OF CONTAMINATION PROVIDED
ON REAR'OF THIS APPLICATION Q ON ARATE ET,
(date) (signature
012-51' MA"frA10 100 5EPA9A 1 ,5;J Tilam A 5Sj9S
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
County Health Department attached to this
3. Submit a Well Completion Report on a form
Health Department.
Date of Issue: 19
Date of Expiration: ° 19�_
requirements of the Putnam
permit.
prov by the Putnam County
A�
e Issuing Official
Permit is Non - Transferrable COQ''
2/87
Yellow copy:
Pin. Copy:
Orange copy:
H. D. File
Building Inspector
Owner
Well Driller
�I „ A
�f,.} e,� a_ -[n4r 4 -. • • � �`�G�O %�'��/ ��.yy_ o,.yc:e.. .e ..A` .. -
rL
W
3
v
. - - -._
_
_ �s.w -�7, /nee a-� �.� ✓�dy
A
PETER C. ALEXANDERSON
County Executive
.9 2;
199� 0-1.
ZI
.7 '.7 —
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225-0310
r
August 13, 1987
L. Olsen and B. Santa-Coloma
Box 198 Pleasant Road
Lake Peekskill, NY 10537
Dear M/M Olsen and Santa-Coloma:
JOHN SIMMONS, M.D.
Deputy Commissioner
JOHN KARELL, Jr., P.E.
Director
Please find enclosed your application to construct a water
well. This application must be submitted to Putnam Valley's
Building Inspector, Marvin Odell, prior to the review by this
-Dept -rtment. :.pA y
received by this office can the approval process continue.
Upon receipt of a submission revised to reflect the above
comments, this application will be considered further.
Very truly yours,
G��
Robert Morris
Environmental Health Technician
RM:amm
Enclosure 0.'
2-
71
DIVISION OF ENVIRONMEWAL HEALTH SERVICES
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