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Home My WebLink About4025DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 83.65 -2 -15 BOX 31 41 r rpm his if T J L � a hr Ell j Iwo I F T io :' r 1 r 1 60 1 * ■ r 04025 I � PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location.-.-_ ..-,.C:qeet-Address:-- C W1 etc TzN-GricT-#' q ke. Ptc k,-.I('. I c %. 4' 1 Map 'r-3 " Itlock Lot(s) Well Owner: Name: Address: Vu 7 I., Vo i / "(-% A e. -r115 if W 114le " -4& 4t e r A14 /f, Use of Well: 1-primary 2-secondary _je-Kesidential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Ioustrial Institutional Standby Drilling Equipment /V1 Rotary Cable percussion _ Compressed air percussion Other (specify) Well Type Screened — '***Open end casing Open hole in bedrock Other Casing Details Total length _Lk-LOR. Length below grade _1Jo ft. Diameter in. Weight per foot /Sib /ft. Materials: LAteel — Plastic Other Joints: Welded L,4hreaded —Other Seal: _Je6ement grout _ Bentonite — Other Drive shoe: — Yes v-No ILiner: Yes _L2No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First — Yes No Hours Second Well Yield Test -LIOI Bailed Pumped C ompressed Air Hours Yield '0 gpm, Depth Data Measure from land surface-static (specify ft) 30 During yield test(ft) Depth of completed well in feet Y_ Well Log If more detailed information descriptions or sieve analyses please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface g p y If yield was tested at different depths during drilling, list: Feet ions Per Minute - Pump/Storage Tank Information Pump Type "I ,.,,,Capacity j- Depth L Model Z"S 25 7 -IS, Voltage _.ka Z) HP 3.IY- Tank Type W X a-VO Volume Id Date Well Completed a 1 11 ) 0 Putnam County -Certification No. b o q --- 1 C, Date of Report —&-i It ha Well Driller (signature) IVY C& NOTE: Exact location of well with distances to at least two permanent landmarKS to be provided on a separate sneevpian. Well Driller's Name ff0fll%gq de rs 4 Al Address: [S_)� j6CL!Ej#_r t.�k (Ile Signature: r d4 C4 -0,4. Date: Al White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 SHERLITA AMLER, MD, MS, FAAP Commissioner gffealth LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Melida Vollerthun 286 Concord Ave. West Hempstead,. NY 11552 Dear Ms. Vollerthun: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Re: ROBERT J. BONDI County Executive February 11, 2005 Well Permit Application for Vollerthun Property — 88 Tanglewylde Rd (T) Putnam Valley This Department has approved the well permit for Well #W6 -05 for the above referenced project. Please be advised that if site conditions and/or site plans change and/or are revised, thereby compromising the approved separation distances, siting approval of the well must be re- approved by this Department. This letter shall serve as record of approval and by initiating construction of the well covered by this approval of plans, the applicant accepts and agrees to abide by and conform to the following: 1. The well location shall be survey located and staked prior to drilling. 2. The proposed well is approved 35 feet from on -site and/or adjacent subsurface sewage treatment system areas. 3. The well shall be installed with a minimum of 94 feet of casing. =ri�zl a -vio t:.l gtiz: disinfec.Lion:_�anit:.srall�bt- installed ari thP-bicb-iiaitg_�vell litie-to :-t�io"':�:..��.�- dwelling. 5. A water sample shall be collected and analyzed for coliform bacteria after the well is drilled. The sample result is to be submitted to this Department along with the well completion report within 30 days of completion of the water well. 6. All necessary Town permits for the installation of the well are required to be issued prior well construction. Should you have any questions, please contact this office. MJB/ky cc: C. Santos, (T) Putnam Valley Insite Engineering Respectfully, 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 0K,. ,-M 9�`f,14,S6 PUTNAM COUNTY DEPARTMENT OF HEALTH IVISION OF ENVIRONMENTAL HEALTH SERVICES ?,.•- ..;'ti?�)F .. N_TR.,IR-WEi j� ON-TO..C'O S.. / please print or type PCHD Permit # L{ f (p --Q S Well Location: Street Address: TownNillage Tax Grid # Tan lew lde Rd. LakePeekskill MaP83.65BIock 2 Lot(s)15 Well Owner: Name: Address: Melida Vollerthun 286 Concord Ave. West Hempstead, NY11552 Use of Well: 1 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 6 gpm # People Served 3 Est. of Daily Usage 5 gal. Reason for 1,-' Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason Pro erty is currentiv without water due to municipal s ste shutdown, and has no well or preexisting well of its own. for Drilling Well Type ✓ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes_17 No Name of subdivision Lake Peekskill ( "Section E ") Lot No. 1 13 -11.5 Water Well Contractor: Norman Anderson Address: 152 Barger St. Putnam Valle Is Public Water Supply available to site? .................................. ............................... Yes No _V_111 Name of Public Water Supply: Lake Peekskill ImprovemfnMfi &�cictPutnam. Valley Distance to property from nearest water main: 15 ft. Proposed well location & sources of contamination to be provided on separate sheet/plan. 0 011 -- .�.A '� e�.t : nature ° -... .. . rpl= S g 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,.providdd, that within thirty (3 0) days of the completion of water well construction, the applicant or their desi�j p ated 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 S"form'•.I;; , provided by the Putnam County Health Department. During all well drilling operations, the applicapt an"', hor r� 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 otlierwist4,�� contaminate surface or groundwater. "'� 01) 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. I _ /1 Date of Issue 2. —11 --O,!S- Permit Date of Expiration 2,- 11=03 Title: _ Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - OwnerV Orange copy - Well driller Form WP -97 TOWN TAX MAP DATA SECTION 83.65 BLOCK 2 LOT 15 N A\ k, Q� aOV V . �U 3C7 Pq.CCLG 5.f/OL//it/if/G.BCGYfi.CNO!!/N //v BGOL.,C S.� ON SI/BQ /I /s /ON .NAP EiVT /TLCO ".L,O,CS gCB,C.9.0 /LL .?GCT /GYti C OIC!/NtFO .ONO G�'ICLOFE'O Gf/. .ifc 6'�CtG.B /C.0 .P.e,OLTf/ CO. /tio•�� e7r ^� F /LBO %ii/ T//e' fP%TNq�ij COUNTU f /4P ity, /B.J L7. SUBJECT TO 'ELECTRIC AND /OR TELEPHONE CO. EASEMENTS, IF ANY, FOR OVERHEAD AND /OR UNDERGROUND SERVICE. SURVEYED AS IN POSSESSION, (No Linea of Poeeeeelon Other Than Indicated). SUBSTRUCTURES AND /OR THEIR ENCROACHMENTS BELOW GRADE, IF ANY, NOT SHOWN. HOUSE OFFSETS TAKEN TO SIDING OR TRIM, PROPERTY CORNERS 97o Ct0 lJ9 Sr/ °a7/i✓ I. WILLI VOLLERTHUN 2. 3. 1( 11 ♦ -- � ... � `1 1� Cc .B< a \ OG CERTIFICATIONS INDICATED HEREOt WAS PREPARED IN ACCORDANCE V OF PRACTICE FOR LAND SURVEYS YORK STATE ASSOCIATION OF PRO SURVEYORS, SAID CERTIFICATIONS THE PERSON FOR,WHOM THE SUR ON HIS BEHALF TO THE TITLE C01 AGENCY AND LENDING INSTITUTION THE ASSIGNEES OF THE LENDING ARE NOT TRANSFERABLE TO AD017 SUBSEQUENT OWNERS. SURVEY OF TRIM. PREPARE WILLI VOL Y LOCATE TOW TOWN OF PU' Co L P`A n„�►. <�. ww u� 4 AI 'A lh 41 + 71A" U-1 'KNIT., LEGEND NOM, These sketches are based on New Y&* state High Resektion Approx. Location Existing Well 0 Statewide 04ftaf (Wholmogery Program (2000 Plot —Prosent) std digital tax e, map kibrmatkn from Putnam County These sketches-* intended to chow Subject Property Approx. Location Proposed Well 0 4Wvxknote property lines, dadM94 sad septk systems for use in assawkig p0 a vell locations orVy Mass sketches arv, not intended far my other Approx. Location Direction Of Ground Slope SLOPE Whose and " not kitanded to be scaled Prior to drMing my proposed Existing SS7S Arrow Points DownhN 41 + 71A" U-1 'KNIT., LEGEND NOM, These sketches are based on New Y&* state High Resektion Approx. Location Existing Well 0 Statewide 04ftaf (Wholmogery Program (2000 Plot —Prosent) std digital tax map kibrmatkn from Putnam County These sketches-* intended to chow Subject Property Approx. Location Proposed Well 0 4Wvxknote property lines, dadM94 sad septk systems for use in assawkig p0 a vell locations orVy Mass sketches arv, not intended far my other Approx. Location Direction Of Ground Slope SLOPE Whose and " not kitanded to be scaled Prior to drMing my proposed Existing SS7S Arrow Points DownhN evil, the appropriate surreys, designs, and permits must be obtained LAKE-EREEKft-L(11- WA TER '-SYSTEN SHUTDOWN' ENGINEERING, SURVEYING & safte aucu., L-IWDSCAPE ARCHITEC TURE P.C. 041&3.100 PLOT PLAN 3 Carr Place - Carrriel. New `Kw* 10512 T" "v f 88 TANGLEWYLDE RD. Phone (845) 223-9690 o Fox (845) 225-9777 I365-2-15 .—Inelt—ong.corn