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631- 589 -8100
83.73 -1 -19
BOX 31
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04104
PUTNAM COUNTY HEALTH DEPARTMEENT r� ?
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
I A I ',VAAZT"D2QMZ@ 4VW31"' � ' "'
OFFICIAL USRONLY
SITE LOCATION
PHONE '6J5
OWNER'S NAME I
MAILING ADDRESS (,2 1 UP- c.), 5 1
PERSON INTERVIEWED- 0-)(-<)p LIN Complaint #
N. e. & Kela,t ions lup .... ..
FACILITY
_ki.e.,ownerj�ni�i _qc
DATE m�
PROPOSED INSTALLER re-A sa
_a-_ PHONE __.3L 7
7
ADDRESS 0-� _REGISTRAnON# LJ
Proposal (include sketch locating all adjacent wells): 10 Q_LA
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.
-4-asA er, -6r
-reported
to the condawns'stated on this f6rin.
TITLE Prp'7, - Aory -
Proposal ape=d with the following conditions:
Procuf�oent, of any Town permit, if applicable.
Subn*qi.bn of as built repair sketch in duplicate showing:
a. COWner's name
b. Street Name, Town and Tax Map number.
ra
C. rbd-&tion of installed components tied to two fixed points (e.g.,house comers).
I. �A: '. stem description (e.g., 1250 gal. Concrete septic tank, three precast 6'diam.
e.'. 1qstallers' name and number.
3. "system "pair . �eormed in accordance with the above proposal and conditions.
Proposil approved.,_
X Gdeep
1 0
Apectorl S Signature & Tide r I
DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC-RP 99ML
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Homeowner:
Mrs. Frances Lama
60 Tanglewylde Road
Lake Peekskill, NY 10537
(845) 528-8654
Town of Putnam Valley
Tax Map Number: 83.73-1-19
Description of Repair to System:
Installation of 500 Gallon Plastic Septic
Tank and 30' Quick4 Infiltrators with 1 Y2-
Washed Stone
Installer:
Philip Leonforte (Registration #45-04)
Precision Excavating Inc.
3 Rochambeau Road
Garrison, NY 10524
(845) 736-0571
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Homeowner:
Mrs. Frances Lama
60 Tanglewylde.Road
Lake Peekskill, NY 10537
(845) 528 -8654
Town of Putnam Valley
Tax Map Number: 83.73 -1 -19
Description of Repair to System:
Installation of 500 Gallon Plastic Septic
Tank and 30' Quick4 Infiltrators with I %2"
Washed Stone (To be Done in Existing
Septic Area)
Installer:
. Phili p 'Leonforte (Registration #45 -04)
Precision Excavating Inc.
3 Rochambeau Road
Garrison, NY 10524
(845) 736 -0571
SITE LOCATION(
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
'1', e,
pmiimum;w�', 4-w—mi
; �, _ �=
_--OMCIAL USE ONLY
PHONE
PERSON INTERVIEWED f nrn g, L c PCHD Complaint #
Name�c'ReTation §flip (i.e., owner, tenant, etc.
DATE � ��- I btu TYPE FACILITY
PROPOSED INSTALLER P[�r►.� Sinr1 "F,c�;���t�-� Tt�_ PHONE $LL< % ^ DG-1 I
ADDRESS c-rysoc REGISTRATION# �j
� •f -®q
Proposal (include sketch locating all adjacent wells): o 2��
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.
as owner, or
to the conditions stated on this form.
TITLE P Ce&
Proposal approved with the following conditions:
U/.-- Procurement of any Town permit, if applicable.
2" Submission 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 components 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
e. Installers' name and number.
3. System repair to be ormed in accordance with the above proposal and conditions.
Proposal approved
pector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NE
�C�a3
/�-
Street Address: Town/Village: Tax Map #
iI/ Map Block Lot(s)
Well Owner:
Name:
Address:
Pftone I,-�
�°°
/G�vC% Lf�/%
PUTNAM COUNTY DEPARTMENT OF HEALTH-
Use of Well:
_Residential _Public Supply Air /cond /heat pump _Irrigation
1- Primary
DIVISION OF ENVIRONMENTAL HEALTH SERVICES-
2- Secondary
Industrial Institutional Standby
Amount of Use
,
gal.
. ♦ ♦
K ..�
. ♦ YM r. - e. . •„ _.
,tlt 0.^��.1 '1.�. ,.:�•.,�..- 4' -�.
.�..., .. ". • _ ... �. :, .• � -. C Y A.
�,
.�� +�.rt •�" .n... Y
Detailed Reason
APPLICATION TO CONSTRUCT A WATER WELL ";> ;- .
,t .5 / , .I
please print or type H�. a f111tvr
Well Location
Street Address: Town/Village: Tax Map #
iI/ Map Block Lot(s)
Well Owner:
Name:
Address:
Pftone I,-�
�°°
/G�vC% Lf�/%
�i✓
Use of Well:
_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 gpm #People Served Est. of Daily usage
gal.
Replace Existing Supply Test/Observation Additional Supply
Reason for Drilling
oe
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ....................................................... ............................... Yes _
No X-
Is well located in a realty subdivision? ........................................... ............................... Yes
No x
Name of subdivision Lot No.
Water Well Contractor: Address:
Is Public Water Supply available on site? ....................................... ............................... Yes _
No
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.
��h��- -� / �y_� -_ : A bli��nk;Signa:ure: �.�i" � �. - .... �= ,..� _ .
_: _ __ .. _.. - -- • �-
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 Countv Health Departmer
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.
ore.
APPROVED FOR CONSTRUCTION: This approval expires'hni)-yearNfrom 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 Commissioner of Health. Any revision or alterat on of the ppro ed plan requires a
new permit. Well Ube nstructed by a water well driller certified by Putnam Co n Date of Issue ® Perm' Is ing Off ial
Date of Expiration Title: YtG Qa► �a
Permit is Non - Transferable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
Rev. 3/06
a Sheet of
* * PU.TNAM COUNTY DEPARTMENT OF HEALTH
._ 1<3� rt. TST OF 3 i� oriN FrN ,_ 4 a � ;�f:A SERVICES
�w y04 FIELD ACTIVITY REPORT
NAMR' Tel:
A nT)R F C 4.
Street Town State Zip.
PERSON IN CHARGE � /1
Name and Title
TYPE OF FACILITY".
FINDINGS:
IAI
3 �
Z7 -0113b X2)33,
Si at and itle
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
04/14/2011 11:30 8452258420 BOYDARTESIANWELLC PAGE 04/04
_ ,.... _ .._ .PU.7NAM COUNT_ Y DEPARTMENT OF HEALTH,
.__......_.. _... _ , ............ - O E V H Xil ..
..., , :.. _� v ............,.. ... ,,...... w 'TI11i'ii�l �N'f;�t= IV ' IRONNi e"i�'i'AL� �M _'i'1� 5� 1•C�S' .::... ... - � :.;.. - ,� .• . o. , :�� � .
WELL COMPLETION REPORT
Well Location
Street Address:
TownNillage:
Tax Map � �
r�'77//1'
Map Block Lots)
EWE ;fie
Well Owner:
Use of Weil:
1- Primary
2- Secondary
Name. Address:
,Residential Public Supply
l3usiness ____.._.Farm
industrial Institutional
7
Air con'd/heat pump Irrigation
Test/monitoring ___Other(specify)
Standby
Drilling Equipment Rotary ,r„_Cable percussion XCompressed air percussion _Other (specify)
Well T pe
Screened O eh end casing Open hole in bedrock Other
Casing Details
Total Length ft.
length below grade _„_ft,
Diameter In.
Weight per foot lb/ft
Materials: Steel Plastic Other
Joints: Welded Threaded Other
Seal: Cement rout Bentonite Other
Drive shoe: Yes —No
Liner; Yes No
Screen Details
First
Second
Diameter in
Slot Size
Length ft
Dept to Screen ft
Develo ped?
Yes No
Hours
Well Yield Test
Balled _Pumped Compressed Air
Hours
Yield gpm
Depth bate
oatsuro from n surlaee state (specify R)
During yield test (R(
p o Completed wall n . J+
Well Log Depth From Surface
ii. ore detailed : -:: ft: - . - ft.
- .....•. ... • a>7�...� ..cs+
information Land Surface
descriptions or
sieve analyses
are avallable,
please attach,
.Water- Bearin
.- ._. - --.., t�
Well Diameter
------ in)
_
..... . - Formation Dascri tipri,.
nom.. _ _
., (A Zia
if yield was tested
at different depths
during drilling
list:
Feet
Gallons
Per Minute
Pump/Storage
Tank Information
Pump Type Capacity
Depth ` Model N
Voltage x0 H
Tank Type V. lu e ;
Fid ,' ; e`�1tI1IP ,
T I r•• jA IAN o kYt �i (i �r Sj,lll li 1'a ;A'Idil L l I' JIjkl',,I.,.,�. 1tl�:11. tII•
N itl I ,1 r •l �t •. l I ,, I �f dib I '$ ' 1': t•:•
s c;ll` 6i ; Y $ IIS'slsr� V p1!1 1 • r �s �'; {' °�i�i °r1;;i I1rf I' t'111� 1' ;.� PiI i 1•'. yyIr' NI' k I + >
T l 1 "y n iiF1{I I s " t tlMllli" L Ipnll)
I. I 1 ! :. I '' lQ��I� 'I �� I y I ` �Y I wSl �'� � (Q�r ` i ��, 1 I • I •I! r .!t jG��IIIij:U :� °: ' P I
A�y� �1f ,t �7 ,fit �ry��r y��p p! In t•
lMi' .4 JrL+�� 4�'�• S' M6' .IN ±�i'iF'. �. ' "•''Ir i'..
dNtI�l� "
. i^� I f °,a, r a, . la " >r Nl r•' wh
i I � " s
Ilt•I.k he'll t'. ; �, tl•.te, I� i� t i' J 1 •'( � Ih rr . .�It�llfii�tlh1U
t
Pufftj ?f 11li!�.
NO FE: exact Location of well with distances to at least two permanent landmarks to be provided on Wparate sfieeVplan.
r•
White copy: HD File; Yellow copy - Building Inspactor; Pink copy - Owner; Orange copy' - Well driller
Form-WC-97
Rev. 3/06
0 PUTNAM COUNTY DEPARTMENT OF HEALTH
I1DIVIKO N OF ENWRONMENTAlL HEALTH SIERWCES
APPLICATION- TO ONSTIRUCT A WATER WELL
please print or type yPCHD' Permit #
Well Location:
Street Address: Town/Village Tax Grid #
60 Tanglewylde Rd. Lake Peekskill Map 83.73 Block 1 Lot(s) 1
Well Owner:
Name:
Address:
Frances Lama
P.O. Box 123, Putnam Valley, NY 10579
Use of Well:
x Residential Public Supply Air /Cond/Heat Pump Irrigation
I- plrimairy
Business Farm Test/Monitoring Other (specify)
2-secondary
Industrial Institutional Standby
Amount of Use
Yield Sought 5 gpm # People Served 2 Est. of Daily Usage ? gal.
]reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) x Deepen Existing Well
Detailed Reason
Well went dry when next door neighhor drilled well
mise co6lvtA t o s c e
for Drilling
Well Type
X Drilled Driven avel Other
Is well site subject to flooding? ................................................. ............................... Yes No x
Is well located in a realty subdivision? ...................................... ............................... Yes No x
Name of subdivision Lot No.
Water Well Contractor: Address:
Is Public Water Supply available to site? .................................. ............................... Yes No x
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on se arate sheet/plan.
Date
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. y revision or alteration
of the approved plan requires a new permit. Well to be constructed by a wate wel driller c rtified by Putnam
County. ;
Date of Issue I l Io Z Permit Issues Official:
Date of Expiratiod // /6 /Q3 Title:
Permit is Ikon- Tlraniff6 rlrablle
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
y , BRUCE K7 FOLEY _
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
LORETTA MOLINARI R.N., M.S.N.
Associate Public Health Director
Director of Patient Services
Environmental Health (845)278-6130 Fax(845)278-7921
Nursing Services (845)278-6558 WIC (845)278-6678 Fax(845)278-6085
Early Intervention (845)278-6014 Fax (845) 278 - 6648
Preschool (845) 228 - 5912 Fax (845) 228 - 6113
Frances Lama
Putnam Valley,. NY 10579
Re: Proposed Well: Lama
60 Tanglewylde Rd.
(T) Putnam Valley
Iwasc Iam
On January 16, 2002, a field inspection was conducted on the above referenced lot by
Bill Hedges, Senior Public Health Sanitarian and myself. The application to deepen the
existing well is approved with the following stipulation:
bcvegiradc -- -- =
As -built plan, Well Completion Report (WC -97) and water quality analysis shall be
submitted no later than 30 days after the well completion by the permitted.
Please contact the writer at (845)278 -6130 ext.2235 if you have any questions.
Very truly yours, WVJ 1��
Daniel Hadden
Pubhz Hea)& Teo iaa
W'.
M
Q,.
John M. Simmons, M.D.
TTIAK
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Deputy Commissioner of Health
- FIELD ACTIVITY REPORT -
Sheet l of
NAME Vnm CeG L vw,
INSPECTION
Orig. Routine.
ADDRESS 6070(00,�CLAA�de-
Lcike
Pee V�Adl
Orig. Complain
Orig. Request
No. \'j str
11
MAILING ADDRESS
Town
PihO t,,4A
TK No.
(U) br r? q
Canpliance
Ccmplaint Capp
Final
P.O. BOX
Post Office
Zip Code
Group Illness
Construction
TELEPHONE,
PERSON IN CHARGE
OR INTERVIEWED
Name and Title
DATE r TYPE FACILITY 0v 0(y
TIME ARRIVED
I TIME LEFT
Reinspection
Field, Sampling Only
Field Conference
L/ Other LA/Cj
Explain
INSPECTOR:
Signature and
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
TELEPHONE: