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HomeMy WebLinkAbout4199DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.80 -1 -51 BOX 32 04199 IN IN Me ' L - 111 , - ' 41% , , f �. �'.. r 04199 -�,� :; .: 1�0R, �TT�A ...- :Iv10L•I�11�Ri�.�'M:S:N:.. - : ; .. .� Acting Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 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 Norman Anderson Well" Drilling, Inc. 152 Barger Street Putnam Valley, NY 10579 Re: Proposed Well Rodriguez 25 Laurel Road (T) Putnam Valley 83.80 -1 -51 May 21, 2003 Dear Mr. Anderson: ROBERT' 3: BONDI -. County Executive On April 11, 2003, a field inspection was conducted on the above referenced lot by Daniel Hadden, Public Health Technician. The application to drill a new well is approved with the following stipulations: ~ 1. The proposed well location is within 15 feet of a property line. Therefore, the well location must be staked by a licensed New York State Land Surveyor prior to any drilling. 2. A minimum of 60- feet of casing must be provided for well protection. As -built plan, Well Completion Report (WC -97), Well abandonment, if applicable, and water quality analysis shall be submitted no later than 30 days after the well completion by the permittee. Please contact the writer at (845)278 -6130 ext.2235 if you have any questions. Sincerely, I D '��) ��J- ( a06`Itl Daniel Hadden Public Health Technician cc: MB, file r EN PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ,�t,� -- j�, -cam APPLICATION TO CONSTRUCT A WATER WELL , / .. -r ,:please pFintoc type :. --PCHD'Perm it = #', W '2 _ v5 Well Location: Street Address: Town/Village Tax Grid # a s L. AuRd Rd, . LAIKEL s ki MaP %3$oBlock 6 Lot(s) Well Owner: Name: Address:. CDS d- .Aue-F.( 'Pe-cX Fo dr % ue .� lCe. ��E �, S� �� 10 5 3° Use of Well: YResidential Public Supply Air /Con&Heat Pump Irrigation 1- primary Business Farm . Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served 3 Est. of Daily Usage _gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dvX- I.ling) Deepen Existing Well Detailed Reason �, r 6 A , Alftkdh VVI be y' for Drilling g Well Type Drilled Driven Gravel I Other Is well site subject to flooding? ................................................. ............................... Yes No 9�- Is well located in a realty subdivision? ...................................... ............................... Yes No 0..- Name of subdivision 13 - 4s a ° -1 Lot No. G Water Well Contractor: I%Anaw A AAQrsa -DI d, Address: (S2 6nr" QrST Pufmcim C" .......... ........ Is Public Water Supply available to site? .. .�,�.... ��.- .�1�?� Yes ✓ No Name of Public Water Supply7'�S�s own/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. -0 p \ e Date: � � Applicant Signature:. � �� Al 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 o dw ter. i f �>�i�111�1nU1v1� � ® Cc,61.Jl Vv1u:ST e Pvo Odd �ov- �, 0l APPROVED FOR CONSTRUCTISN: This a�roval expires two years from the date issu�d 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 I I Date of Issue 5-2'Z -o -i:�. Permi Date of Expiration ,,5-- 22 Title: Permit is Non - Transferrable White copy - M file; Yellow copy - Building Inspector; Fink Copy- Owner; Orange copy- Well driller Form WP -97 .7 cl f'Aklkt- R.— FOLEY Public Health Director 'CA) -1 b - 0 3 41z :z( -4 LOREITA. MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Service's DEPARTMENT OF HEALTH I Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC -(914) 278 - 6678 Fax (914) 278 - 6085 PUTNAM COUNTY DEPARTMENT OF HEALTH SPECIFIC WAVIER NAME: Ue-L � ADDRESS' tavweA La. -L-1,0QYA I li WY (O5D SITE LOCATION: � viA e DATE: -5/ -7/0,5 STAFF PRESENT: aftfe-ok.. Rob M.. Mike B.. Ado".. Gene R.- S 1 . , AW, 1 A SPECIFIC WAVIER REQUEST: . �110 � d,1`CS'6ACP-C-) -k 2-5S 0� DOES TH*E. PROPOSED VARIANCE OQVEST,, HE�4TH HAZARD OR ON PR,6bLEM�- -ENVIRONMOENTAL CONTAMN01 X + YES NO WILL PISAFMOVAL RESULT IN XS14 rNIFJCANT HARDSHW? ++. YES NO DENIED Slice of� PUTNAM COUNTY, DEPARTMENT OF HEALTH DIVISsfO V7�OF:.g- iVftiONMENfAL'HEAtI H SERVICES " FIELD ACTIVITY REPORT V11 Me- D�LAV�� iwD LA CW A►L1 VCk Street Town tte Zip PERSON IN CHARGE Veil �il�Ii v'� — —r ^T T _ ^— — TN me and T Title - - FINDIIJGS: '�CR � l � WeA tAv, Signature and Title I acknowledge receipt of this report: SIGNATURE, 12 /9h TitlP- �i ti Stf P IV A ,FAA DEPARTMENT OF HEALTH W Division of Environmental Health Services 4 Geneva Road, Brewster, New.York 10509 (914) 278 -6130 ICATION�, TO.::.00NSTRLtCV A --,W 1 •T Rr :�W}'sI;L ° . ;�;:.:::.r Win-: . _:a -�; -. PCHD PERMIT 41A.5- / / WELL LOCATION S eet Address To Village Cit Tax Grid Number WELL OWNER Name Mailing Address 6-0 tbi L. OS-6 UPrivate ,OPublic USE OF WELL 1 - primary 2- secondary MAdSIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 BUSINESS O FARM O TEST /OBSERVATION 0 INDUSTRIAL O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT !�:: gpm /# ffitPLACE EXISTING SUPPLY O NEW SUPPLY NEW DWELLING PEOPLE SERVED /EST. OF DAILY USAGE___gal O TEST/ OBSERVATION Q ADDITIONAL SUPPLY 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING T ° , J50_, v. WELL TYPE 96ROI LLED DRIVEN DDUG GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES L---'NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: L_4ke- Lot No. WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: ✓YES NO NAME OF PUBLIC WATER SUPPLY: 1,4ke, I' TOWN /VIL /CITY f� --4stw V,4 k� .----DISTANCE,. TO PRO�ERTY..F.ROM NEAREST. WATER MAIN:... LOCATION SKETCH & RCES OF CONTAMINATION PROVIDED ) // f 3 �-1 ON SEPARATE SHEET (da e) ignat re 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 thirt -y (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 Roy Fredricksen PO Box 950 Mahopac, NY 10541 Dear Mr. Fredricksen: ,arF•. r.,- r:I•�.- +aca�: .. _. .'..:.. '+c.��.,- ... - •.as�i•.: - -nc— -. ai. r- BRUCE R. FOLEY Acting Public Health Director DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 TeL (914) 278-6130 Fax (914) 278-7921 January 31, 1997 Re: Proposed Well KLJ Construction Inc. (T) Putnasm Valley 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: 1. Separation distance between the proposed well and septic is approximately 75 feet, 100 feet is required by today's standards. 2. Expansion area for the existing septic system, 100 feet from the proposed well, is not available. _... - -Wight of the. foregoing, your. application is hereby denied__ It is advised that the proposed addition is revised to meet current standards. I may be reached at ext. 166 to discuss this possibility. Ve truly yours, �iw AW44-V Robert' Morris, P. E. Public Health Engineer R,NVjp NEW YORK STATE DEPARTMENT OF HEALTH Specific Wait/ @r Bureau of Community Sanitation and Food Protection from Requirements of Part 75 and Appendix 75- A,10NYCRR — l ' forfndliduaftiaus8firo fd`S�tVVBt� y ..__ ems Reason Reason why site does not meet 10NYCRR Appendix 75 -A (check appropriate box(es)): . Separation distance cannot be achieved. Excessive slope'. High groundwater. Inadequate depth to bedrock or impermeable layer. J Soil unsuitable. L] Other (explain) .................................................................................................................. ............................... 2. Proposed design or conditions of waiver:PVOPOSE� . ........ .... w.............. ........:...................... .t.J�....t.....w..l.u.sM ..... -..... ... . on. s .....:.........:. .... ............................... � t ...... . . . ..... ... ... .... _.. ..... _. ...... .. _ 3. The proposed design may have the following limitations (check appropriate box(es)): Increased risk of well or spring contamination. Increased risk of surface water contamination. Expected design life of the system will be diminished. t a Operation of sewage. system is subject to mechanical problems. Other(explain) ......... ........................................ ...:.................................. :.......... Additional information attached 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. EPHESENTATIVE 0 ISS F HEALTH ........... f. ... 5- -22-3 DATE........... ............................... ......... ORIGINAL - Local Health Agency COPY - Applicant/Design Professional DOH -1326 (7/92) (GEN -1521 14 -16.4 (x S7) —Text 12 PROJgCT I.D. NUMBER 617.21 SPQR Appendix C State'Environrtiental 0uallty Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1-- PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 11.(A SPONSOR�� , J vo ' PR (:HECT NAME 2 03 W4 v�e2 w - 3. PROJECT LOCATION: f � iAW� VOI. Municipality iJ� County Ill 1M 4. PRECISE LOCATION (Stree address and road Int tions, prominent landmarks, etc., or provide map) 2rJ Lawrei G&A 1 ?)?0. 5. IS PR OSED ACTION: M New. ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PRO ECT SRI FLY: o ©4 ss�s a Db �oA ov`e o 7. AMOUNT OF LAND AFFECTED: ((�� 0 °Zq 0 2A Initially acres Ultimately acres 8. WI ROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No It No, describe briefly 9. WH IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ 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, S1kTE OR LOCAL)? 0 [ (o If Yes yes, list agency(s) and permll/approvals 11. TOES ANY ASP ,RCT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? CKes No If yes, list agency name and permittapproval 12. ASSt RESULT OrF,,PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? -`Iles W No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE / f I;- — ` —03 dvo`�v ` Apolt+nt/spo name: Date: ` Signore: - 11 • — -�j 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 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EX 51) ANY TYPE I-THRESHOLD IN 6 NYCRR PART 61712? If yes coordinate the review process and use the FULL E;AF ❑Yes, ­b: 'WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be supersedes y another Involved agency. ❑ Yes LJ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be 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: 00 C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: No 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 Iv 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. LA i r � C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. Nv � .. . ....... D. IS THERE, OR IS TfiERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes M No 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. e 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: Name of Lead Agency Print or Type Name 9 / Title of Responsible officer Signatur Wh We—sp,&4ble Officer in Lead Agency Signature of Preparer (if different from responsigle officer) Date ,b E �f i s. {'r i -L- �^1 joa IT raj �� f -j r� ►-�? c I O