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HomeMy WebLinkAbout4363DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -2 -13 BOX 33 04363 Jr' ,61 ti r ' ' kill 04363 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .� , -. ».. r "r,. _L7 ',•! -. o- �" wG°o.:A'�t3!S' 3- Z�' ;L Z i�" ... Eaa WELL COMPLETION REPORT Well Location Street Ad ress: fl�� Town/Village: Tax Map # Map Block Lot(s) "GPS ,1a Well Owner: Name: Address: / Use of Well: 1- Primary 2- Secondary Residential ^Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring `Other(specify) Industrial, Institutional Standby Drilling Equipment _ otary _Cable percussion _Compressed air percussion_Other(specify) Well Type Screened L pen end casing r Open hole in bedrock Other Casing Details Total Length Length below grade aft. Diameter 41 in. Weight per foot /.5 1b/ft Materials: teel Plastic Other Joints: Welded ✓ Threaded Other Seal: vCement grout Bentonite Other Drive shoe: Yes l� Liner: _Yes "o Screen Details Diameter in Slot Size Length (ft) Dept to Screen ft Develo ped? First _Yes No Hours r Second Well Yield Test _Bailed _Pumped VCompressed Air Hours Yield 1 gpm Depth Date Measure from land surface-static spec ) 30 During yield test ft Dept o compete we I in ft. �Oc� Well Log If more detailed information descriptions or._,... sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter in Formation Descri tion ft. ft. Land Surface /0,%S b p U� .4 /" 0 e /V to 3 � oo _ _ ry :., e. _ . ' If yield was tested at different depths during drilling list: Feet Gall9n, Pe Minute Pump /Storage Tank Information "� �`�'` ' ' Pump TypeB knle4S FUe Capacity !2). Depth Model .S_ Voltage 3y HP r /Z Tank Type t,r Ir S—b Volume Date U,,iI%;.' ll "com' "feted �# r i 4 � � % ��' ....�:.. r. a._,, . r 1Nell Dhil" 3 Vii;. �l� z,,��.�5 �r�w:�r .r. c�, .Soi 3'r � '�. � �d Pum Installer ,......R..... _..._: PG Ce'rt�ficate # ' ` (� � �. �.rxl �,{�. -:k xd :" �.�i s �.::5 s^`z ,^k : },ih3;n. i a - .a- S' y:, K' � lie �:�i:� i PC Certiftcate #� U w .......... L. NY Staten# $ % Date of Report ` AK s.i ' ;' u..:x fit- ai r1y; .. ��jH Fryr l.. l�i A•� �h dt ! �( Y` } S -. 5: : `1: WeIIIJrtl erName &Add °ss #k�� mil w�� A .. -1 to +.•.^ IaDrllek Pum r hi 11er Na vw�� tltlress .r , . ' p s �K » 5 "{ �' ;yn, :�' #:a? '''��t '� =' + Pu ` Installer "igna re) NOTE: Exact Location of well with distances to at least t*o permanent landmarks to be provided on a separate sheet/plan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -9T Rev. 3/06 YML ENVIRONMENTAL SERVICES 321 Kear Street /orktown Heiqhts, N.Y. 10598 7j;.����,/�«�;�'�� Albert H. Padovani, Director LAB #: 1.704476 CLIENT #: 60299 NON STAT PROC PAGE: 1 of 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ HADDOCK, THERESA 194 PEEKSKILL HOLLOW RD PUTNAM VALLEY, NY 10579 SAMPLING SITE: 194PEEKSKILL HOLLOW RD : PUTNAM VALLEY, NY 10579 COL'D BY: ANTHONY ORTIZ B NOTES...: BASEMENT ENTRY POINT ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE 08/08/07 MF T. COLIFORM RESULT ABSENT /100 ML DATE/TIME TAKEN: 08/08/07 07:15 DATE/TIME REC'D: 08/08/07 01:40 REPORT DATE: 08/09/07 PHONE: (845)-528-2215 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COL7FORM METH: MF ------------------------------- NORMAL - RANGE ABSENT METHOD SM 18-20 9222B COMMENTS: ` MFTC THESE RESULTS INDICATE THAT THE WATER AS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDINC���-THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Av SUBMITTED BY: Albert H.-Q'a---TAovan1i-,. M.T. (ASCP) Director`~ ELAP# 10323 ii• 1 � PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ..7.. r :.r.rv.f''.. ;mo w:, t. :� c. - yye- lyf,ir::r t.:.;:,:, •d.. ..:� .n.:': {: .i:.;—, '.7 xi �4Yd1� '�..%•i•`IE. WELL COMPLETION REPORT Well Location Street Address- lq,� D Town/Village:. V u 11 Tax Map # Map Block Lot(s) Well Owner: Name: Address: rr // // ngAa A � � e e /� cf 441 /7T1 11 dW U^ e Use of Well: 1- Primary 2- Secondary AAResidential _Public Supply Air cond /heat pump _Irrigati n Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment' _Rotary _Cable percussion Compressed air percussion Other(specify) Type pen _Screened pen end casing _ Open hole in bedrock _Other __W Casing Details Total Length L- f- Length below grac7e'_�5ft. Diameter -in. Weight per foot lb /ft _ Materials: " teel Plastic Other Joints: Welded Threaded Other Seal: ement grout Bentonite Other Drive shoe: Yes I--No Liner: _Yes _No Screen Details Diameter in Slot Size Length ft De t to Screen ft Develo ped? First I No Hours Second --d—Yes I Well Yield Test _Bailed _Pumped Compressed Air Hours f"- Yield / 0 gpm Depth Date Measure from land surface-static (specify ft) 30 DDuring yield test Depth of completed well In ft. 3aa Well Log If more detailed information descriptions or. ' sieVe�analyses'` � • are available, please attach. . Depth From Surface Water Bearing Well Diameter in Formation Description ft. ft. Land Surface A v v �,✓ a•o _ ,. b- 5��1JV►r. � • If yield was tested at different depths during drilling list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Sk t�►,crs 0: Capacity_ Depth --Z Model / " Voltage �i �� _ HP )- Tank Type W �` aps Volume /� v Date Well Completed u ':'� P :,'A"S �. '.h! '� .� �, +i F' � j,,�: 3'LL'F t `�.•.Y 1Nell Driller, PC Certiftcate#, ; Y _ P�;zNY�Stateh# STM' �� - S �� � C :'�� iv4 t'i`>• ���.[.: � �"xy�k §5�K }M� Y t .T '.:: -1 �.T 'x: fl .iPil�'# k: k ':�:'i� p Y 1°�''i: RurnpInstallerxPC `'Certificate: ° #k `� ;L�B�;°�'. r x " r q .' P �>• M V`SVO \.�� 3 �'#� x,� M�`k"i5 ?y�y � Sf lY: A��i. ix� k�` %1j °NYfiSateW #�4C •V''r'�V44•�i�i''N Date;of; eporthl.�i; �• ..�) W '..'��x � k �Jv.Y1H i "-":'' , °�r M 'J rta �• r u� _ � :.�G +�M t41.y ��,'��(�y^! ✓i Y! # [ st4 ?' Ix A" �x?x t .� �N 1 xi 3Y OiSY1 rNxM'' Well�riller Nan3Address ; xa ity� 3i�5 +s ,x^.Y. ". hf �; ;,c ° S :.`>k"";4 �i• f * 'n » is 'i it J �� •� Y i+efh .:_.- t,.. ...tea, i. - .9'.}. v`:�. M. r... "� x'';�:�, ..: '�h:•k . .?%.,x.�:.r?�.. of �k.�s. :.k:� �ttv*C'k•v :I:w, WeI:IDriller (si ure �'• a d A1.r,"�?,y�� :.. x^u �5i t; ,�` 7� a 4'�d*�I 'd -, �l'wy'"M `tR 1.3 rf�l AG 1iI�,li I. 8 ek°x .... .x1i.f,,. �� ....l ..:.. "� WI"�`NK...iF�>x.SM . ��� r;N�. Pu Instal RAJ me & iAddress'nxf , b� "a .0 i , 4, .. -...av ».:. 5, iY...i�uw.37iv'�,a.. 6�ir. 'tt..� �4 ..ta..,A��S.. .�vi✓�u�6 ? �e a'S�' .�'a Pu I -A n .4� . x' w�. xiY{x J.' '�."F".1�'�wJh:�ax�u:�+#I -.:•F� .lSax X4ti4� S:�nF NU i t: txact Location of well witn distances to at least two permanent landmarks to Abe proMed on a separate sheet/plan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 YML ENVIRONMENTAL SERVICES a 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 • ;AJbert ;�s1r •F?�.�.���-n =i•;•. D4:•r����r- - , _� .:; .., r :� _ . -,: , .�-- �-;z.: , LAB #: 1.704476 CLIENT #: 60299 NON STAT PROC PAGE: 1 of 1 HADDOCK, THERESA DATE /TIME TAKEN: 08/08/07 07:15 194 PEEKSKILL HOLLOW RD DATE /TIME RECD: 08/08/07 01:40 PUTNAM VALLEY, NY 10579 REPORT DATE: 09/21/07 PHONE: (845)- 528 -2215 SAMPLING SITE: 194 PEEKSKILL HOLLOW RD SAMPLE TYPE..: POTABLE : PUTNAM VALLEY, NY 10579 PRESERVATIVES: NONE COLD BY: ANTHONY ORTIZ B TEMPERATURE..: < 4C NOTES...: BASEMENT ENTRY POINT COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL — RANGE METHOD 08/08/07 MF T. COLIFORM ABSENT /100 ML ABSENT SM 18 -20 9222B COMMENTS: MFTC THESE RESULTS INDICATE THAT THE WAT S NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDI E NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. SUBMITTED BY: �--- l m Albert H. do ni, M. .(ASCP) Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH a IVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type $CHD.PermltA. Welilocation: .. Sheet4&,.J$ Ad ,. ss:- .. Town/Village Tax Grid # rLP-- Pv A 1� I)O NT Map jpUBlock 2-1-Lot(s)/3 Well Owner: N e: S Address: ,Q 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 *A ! gal. Reason for v7Replace Existing Supply Test/Observation Additional Supply Drilling 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 Is well located in a realty subdivision? ........P. ...................... ............................... Yes No Name of subdivision Lot No. Water Well Contractor: ly, , j$-1).P C� ,S'd Address: &Pt" 92-45 �- ;kfzaw1 al Is Public Water Supply available to site? .......... yI. 6- � ............ ............................... 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 s sheet/plan. Date: �� pplicant Signature: ..:z: Aj41 PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 16rof they ?" Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code androvidwed that,within thirty (30) days of the completion of water well construction, the applicant or their designated t-, representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance vh th rri requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on orm ::O X � provided by the Putnam County Health Department. During all well drilling operations, the applictt an?g6� well driller shall take appropriate action to assure that any and all water and waste products from stwh 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. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water ell iller c ified by Putnam County. Date of Issue jli Permit Issuing cial: Date of Expiratio Title: Permit is Non - Transfer •a 1 White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 041111 O I R) \IE 119 1 D1 I"N"I)IaI1 a I FS (I >I a III 01I f!I DffVffSII (DN (DIF IENWRONM ENTAL HEALTH S ERWCCIES please print or type TO 'ABAN> 0 A WXT>ER WELL PCHD PERMIT # Well Location: Street dress: T Nillage T Gri # Welll ®wyne>r: amen j (Address: Well Type: V Drille Driven Dug Gravel Other Depth Data: p tv Well D th ft Static Water Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned I- primalry Business Farm Test/Observation Other (specify) 2-secondary Industrial Institutional Standby Water Well Contractor: Name: , Address: Reason F®Ir J� ' fleL !✓ „6,�✓ Abandonment: — Description of Work To Be Performed: Date 3 Applicant Signature: x' P ERMff 1' This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the inf a ion deli7ted on the application for this permit has been completed. ; /' n Date 6f Issue Permit Issuing Official N Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 J 7777- FROM L.Ettere 914 526 2473 ti r p e G b o F � Q ti •y4 T ? a T k. V h p N N } s 1 xH' x law 1 @y7 } 4'9 W rn J I b b a R N � � I p I IJ i _ � I 1 m � ( b ill r 1 ty a FAX N0. 914 526 2473 ti r p G b o F � Q ti •y4 T ? a T W N N law 1 @y7 } 4'9 W R Jan. 10 2005 12:O9PM P3 Y 8 R2 o A Ing M 9$ 9w' ilyA E44J� .- Z; . _ A- ".. g. ;;- - .. —:. �s�ss -1 x Q � ;rr= .� CP xs ;air. < C Z{•• Gi— u�iiww ZME IyA wmia �M�it �i iw(aas� E CP.1� y A �BOap �w �w iL m ml5 �/0.p m�pQy r�l ',[}$pl p �' °�• mpX �.i ..' H O J6Z .ym�y- �y=1tiM {T r .� 6 • yppy Sb��+j1 p�N g I(Dw[� x Cy T fI1 Z 9� 'Td 9 I K G .7 T � 8 ' O O 4�1 I•Iwf Cg V A 0 r! ? ._^. nF ; g cV o kjx a d m CU e-1 @ m a-1 ra In N CL N l>7 E71 Z LL Ol Dl w J F Q' It 1 EA31D0 RE'r 2/81 14 W YGAK STATE AUDIT CONTROL CODES SVYIS/5Bl/0U DIVISION OF CaUA112ATION ANO ASSESSMENT icTR,EY 3 P 2 80 0 ' 84.—Z-93 L rARO IM DT L 9 • ROME l - L45TEID r RESIOENTIAI. FARM AND VACANT LAND PROPERTY RECORD CARD M • MEASURED ONLY VTE fROPEATY SITE INFORMATION SECTIOIN L VABER CIASI _ C1rV— PUr9AP TOWN TWN— PUFNAA WALLEV S i TlYk Ac7vm l 5 SOURCE a � n S` 1 r 1 • ENTERIORNWECT" r' L JffX lIOOOEOOE l�'r��.aaou�•L s�N,��1 `t?,p�S \ ♦ v,� ��r•�at�- fF L s w) fS TAR M iKN FA3 m d m CU e-1 @ m a-1 ra In N CL N l>7 E71 Z LL Ol Dl w J F Q' It 1 EA31D0 RE'r 2/81 14 W YGAK STATE AUDIT CONTROL CODES SVYIS/5Bl/0U DIVISION OF CaUA112ATION ANO ASSESSMENT icTR,EY 3 P 2 80 0 ' 84.—Z-93 L rARO IM DT L 9 • ROME l - L45TEID r RESIOENTIAI. FARM AND VACANT LAND PROPERTY RECORD CARD M • MEASURED ONLY VTE fROPEATY SITE INFORMATION SECTIOIN L VABER CIASI _ C1rV— PUr9AP TOWN TWN— PUFNAA WALLEV EMERY ' TlYk Ac7vm fkar SOURCE a � n 1 r 1 • ENTERIORNWECT" r' L JffX lIOOOEOOE l�'r��.aaou�•L s�N,��1 `t?,p�S \ ♦ v,� ��r•�at�- fF L s w) fS TAR M iKN FA3 m : - INIERFDR flEEUSAa �: ` L STep ti S�•c�to.- Ali: •PF d' . L f 3 • TOTAL AETUSAL 21mL6 CRDE * IA`TE`R 14ELLE PROP CLASS 7tC A = ESEIWSTE � � 5 - AO EtTTffV SEWER t WINE " "- l EENVATE 3 ame/ Mt R09ERT & CLAUDIA 21U WATER 1 NONE TPRIVATE 3COW/ Pl}811t WORM j � i Im r, LMT SClEdOI [EST E • ONWER 4. OTHER 9 P E E KS sC Y L L HOLLOW 3F2d0J 2= RELATIVE 5= W U 3 vTaEFIES I fEYtE 1 GAS 3 ELECTRIC r sASs EIfCTREC 3 - TENANE 6 ASSESSORIGATA till 01- IQ 5 91EW 031 a[ 10 G VhTMFSS 1 GTIER . w PRICE SUE Dan tow SUE SITE DESIRWITY 1 WFERIOR 2 TYPICAL 3 SUPEROR U SALES IPEE mAFUN DOOES ' ' 1 . f AR:16H80RHODO I11VE 1 RURAL 2 SUBI BAW 3 UBEIAN 4 UMMERDAL t 1 ' LAMA TEalM AREA REVEMR; SAE£ TYPE I - EAND DRLY #UGNBORH000 RATM 1 B`.L69Y AYESaL 2 NERA6E 3 ASOYE AVENA&E 1 • WX ONLY i 3 - LAND A RtG& f RVAO TYPE / NONE 2 VIONWAD 31NAROYED 31Vt3 to Qw,, PFIQT lOC lw SLtI rar nar • 0.0m o als s1u VALID l 0 • VNAW SALE AUDIT CONTROL SECTION I • MW SALE P LIA RA1E 44 i r AIEITES: 1 REIEAiG3DE . STAWCDDE 6NAEU BELOW DOES 6197 AN COITTEFEIS VEF"FRO. A1.T IM 1r DATA WAS COLL Rl 1TAt3 MMIXE. CDl {ExiOR DATE HMJOOYn TlYk Ac7vm fkar SOURCE a � n 1 r LAND TYPES t t74.o.t tdP {l l�'r��.aaou�•L s�N,��1 `t?,p�S \ ♦ v,� ��r•�at�- fF ! r`-. it 1'V4C 01 PRIMARY OB 1ri5711o� T I ORtE1AR0 02 SECONDAEET OT 6fD ikho I I REAR 03 UNOEVEMIPEO 08 W&MLAND 11 YNEVA26 1 SALES INFORMATJDN SECTION !' «DATE OAMU -V� I SALE PRICE TYPE VA—DO--T LAND' fWNT FEET I OFPTH OANO BREAKDOWN SECTION ARSES it i i Cp S VAK FEET rG— d.�If4F�' "w a � n 1 r LAND TYPES t t74.o.t tdP {l l�'r��.aaou�•L s�N,��1 `t?,p�S \ ♦ v,� ��r•�at�- fF ! r`-. it 1'V4C 01 PRIMARY OB 1ri5711o� T I ORtE1AR0 02 SECONDAEET OT 6fD ikho I I REAR 03 UNOEVEMIPEO 08 W&MLAND 11 YNEVA26 L STep ti S�•c�to.- Ali: •PF d' 1 Ot RESI"L 62MU69 li 1AULANU a3 TIMABEE t6 TVLIERFRONT 1i IEASEO LAW it i LAID CODES t Y S VAK FEET SON 1YlR IW WFIU• LAND TYPES RTNG - hp cu EKCE % 01 PRIMARY OB 1ri5711o� T I ORtE1AR0 02 SECONDAEET OT 6fD ikho I I REAR 03 UNOEVEMIPEO 08 W&MLAND 11 YNEVA26 L 1 Ot RESI"L 62MU69 li 1AULANU a3 TIMABEE t6 TVLIERFRONT 1i IEASEO LAW SOIL RATING INFLUENCE CODE 1 P POOR 051 r, LO 1 ,PRY N KORMAI 061 01 • EO 2 IOrATRL`E !_. G MOO Nil GI - Oa 3 SHAPE X031 a I .54 A RESTRICTED USE . F till 01- IQ 5 91EW 031 a[ 10 G VhTMFSS 1 GTIER . SNATENFRONT TYPE 1 . f 1,1111' w Te NTAL ....... . . . . . 7_ 7 PCHD.'PEA ur Tox ki map Bi6ok. * DU ot Dat® . . . . . . . . . . . A&Cb P. YZ% e tog ,4'S. �}•��Yg''' y' :St Iy4.r' Ait ;p4, +! ,;' -+• ,J .l•: ;'y• .r'. H:,.r'.r'(,,•i,• 61. 14 0L•. C.; 4e l.•'�$r' ;:'�.:. �:�}fr,','A.•,ll.l:t�fyoi :�1 ��'^ ,�r•� y'vl '��` (�Y'7''' ✓. 'I'r','1' ;',, lr��.. r. 1.4 ci tmd.ei M, I MU