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BOX 36
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IN L .I
AM IN
IV;
DEPARTMENT OF HEALTH
Division of Environmental Health Services
PW COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
AFPL' ICA'PION" 't'0 "Ci)NSTRiJC`f- A WA!rVR 1 ELL''
PCHD P IT
#
WELL LOCATION
Stree Addres
To V'lla a City Tax. G
id Number
WELL OWNER
Name
Mailin Address
Aprivate
O Public
USE OF WELL
1 - primary
2- secondary
A RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
0 INSTITUTIONAL O STAND -BY
O ABANDONED
❑OTHER (specify
0
AMOUNT OF USE
YIELD SOUGHT_, gpm /# PEOPLE SERVED /EST. OF DAILY USAGE /OCO gal
REASON FOR
DRILLING
QNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY [3 TEST /OBSERVATION
>6PLACE EXISTING SUPPLY O DEEPEN EXISTING WELL .
DETAILED
REASON FOR
DRILLING
WELL TYPE
5DRILLED
ODRIVEN
E]DUG
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES �NO
WATER WELL CONTRACTOR: Name /�Sddress :
r
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /Ylrbf£-i1fY...
DISTANCE TO 'PROPERTY FROM. NEAREST' Wa ER MAIN: :...._.. .... .. -..
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
cl-2gREAR OF THIS APPLICATION bON SEPARA
(date) (s ature)
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 requirements of the Putnam
County Health Department attached to this permit.
3. Submit a Well Completion Report.on a form prov by the Putnam County
Health Department.
Date of Issue: 19 }
Date of Expiration: 19 ermit Issuing Official,
White
Permit is Non - Transferrable copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
MARV;N O'DE!.t,
Inspector
11
PUTNAM TAUT
TOWN OF PUTNAM VALLEY
BUILDING, ZONING, AND SANITARY DEPARTMENT
Robert Morris
Dept. of Env. Ifealth
110 Old Route 6
Carmel, N.Y. 10512
Dear Mr. Morris:
August 31, 1987
Re: KREIBICH - TM4 /105 -1 -8
Hollowbrook Road
TOWN HALL
PUTNAM ,VALLEY, N.Y. -
1914) 526 2377
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.
MOT: es
Very truly yours,
//%/`�:_C/1�11--_ - e-�� .
MARVIN O'DELL
Building Inspector
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I
NORMAN ANDERSON INC.
Well• [?r'rflin
Sox 152..
PUTNAM VALLEY, NEW YORK 10579
(914) 528 -8698
If il
1:
CATE
F'EBRUARY..24., -193a- - l
NUMBER - v
JANUARY 15, 1988
GRET KREI3TCK
3332..
100 ELEECKER
STREET,
APT13A
2- 455' C $7. per foot
3185.
New york, N.
Y.
21' 6" casing - $7. per foot
.147.
10012
----------
--- - - - - --
3332.
- - - - --
--
1 gallon per minute 11/9/87
TERMS:
PLEASE DETACH AND FCTUNN
—N FOUR NEMITTANCE
BATE -
'- CHARGES AND CREDITSr BALANCE
PUP1P :. 7052 621
BALANCE, FORWARD,
GRUNDFOS 3 14IIP 3 T -DIRE 230V P(Ji�IP INT /BOX
1- 455'
@
$7• perfoot
$ 3185.
--
torque.arrestor
21'
6"
casing @ $7.
per foot
147.
--
3332..
-
z gallon
per minute .11/6/87
2- 455' C $7. per foot
3185.
--
21' 6" casing - $7. per foot
.147.
--
----------
--- - - - - --
3332.
- - - - --
--
1 gallon per minute 11/9/87
J�JELI, TOTAL _
6664.
--
PUP1P :. 7052 621
GRUNDFOS 3 14IIP 3 T -DIRE 230V P(Ji�IP INT /BOX
2 pit-less adapters, 2 check valves'
torque.arrestor
snaked 60' wire (10) 60' hiflex 1601
1" plastic T
labor
420' SCH801 couplings
425' re (10 )
.p�y�s o �+
~ ntY+ 7
NORMAN ANDERSON; INC.
_2. ?14647
:Yorktown Medical Laboratory, Inc. LA b _
321 Kear Street . Date 'Taken: _c;-16
Yorktown Heigh is, N. Y.- 10598 Date Rc' d :
(911).245-3203 ., _ _s�t.>.�4�c.ovkPi
17irecto7AI cet .Padovant.if.T (ASCP) Collected By.
Referred By.
(- -1 SamDle Locatio_ n:
NY
L J
-38 Time : 41 �10'P/1
1-0 Time: 2, rrn el
Phone # 1Lj7,5_g25,
Phone # `Sample ^:pe,
Repeat Test? I (checf -_nee
LA3z C ?A7.0R-Y R 0 R T ON T; QUALITY 0 ' WAT�R
:iOR�.; :._C '.0:.- '4 ETA LS L) ? ?ICROBTOLOGICAL (CFU /100nL)
_ C::_or de..
r Detergents, MBAS
Hardness, Tota,1
Nitrogen, Amnonia
'litroge ^., Nitrate
P:osphat e , Total
Sulfate
Sulfide
Sulfite
G E N AL SACTEaIA:
K Standard Plate Count 171-
(CFU /1.OmL).
MEMBRANE FILTRATION T EC NTQU:
..Total Coliform
Fecal Coliform
Fecal Streptococcus
�'OST PRO3A3L rU :43SR TLC::i1IGUC
?ota'^_e
pion - 0���_e
CTS
Sam.le Sta:
0utzo_
P ,10 3
_ C1
"'2SOL
_ 0 aOH
Zr.O=+c
`ia2S2C3
Co.pce- Ct er.
Iron Total Colifor:n Index
L-e a d -
ManS,alnese Fecal .- Co.l.if- o..—m. - In-dex. hnc•o-'
. .. j r.� .�.0 4'Z.y . ✓ - .+v ... _�.. � -_... �.. Yv '- ^i'._ -• .q - ....... r a .... .. - , .� ..c - 5�r�^+'{' .a.s
q Sodium KEY FOR T" ?'•fINOLOGY L., L °C
Zinc r GT.40C
MISCELLANEOUS
p✓: (units )
Color (u;its)
_~ Odor (TON)
Tur.bidity (NTU)
N/A = Not Applicable'
LT = Less Than ( <)
GT = Greater Than (>)
TNTC= Too Numerous To Court
CON = Confluent ( =TNTC)
NR = :ion - reactive
REMARKS/C-- CXMENTS ( For Lab Use)
pH 2
p" GE g
_ p G _ 2
Other.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A
SATISFACTORY S'AN'ITARY QUALITY ACCORDING TO T N"' YORK STATE DRINKING WATER
STANDARDS, FOR THE.PARAMETERS TESTED, AT THE TIME OF COLLECT .
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA - D HKING WATER
CODES, FOR TAE PARAME;ZR, S TESTED, AT THE TIME OF COLLECTION.
/x/ �!��`,I V 1 1_1 2/86(Rvsd7 /$7) RW
Albert H. Padovani, M.T. ASCP), Director
"k
LAB y _ 2.014/-.47 %
�Orktown Medical Laboratory, Inc. — - - --
321 Kear Street Date Taken: Time: ��
> Yorktown Heiph cs YPl. Y. %059;8: A_ to Re d :. �. Ti me. •i
� - -_ �r '-. .' r- _ice ': a - 1w .► as ._ v :r ,.�. <r— .. - "�,� .ax= �'--
(914)r245 -3203 Date Reported.0�
Director: Albert H. PadovaniAT.(ASCP) . Collected By: gp ► `" k
Referred By: 0,nSSn)aR iAgd,a
FSample Location: etkh4w, r
� OVh
L J
LABORATORY REPORT ON THE QUALITY OF WATER
Phone # — 25
Phone # I — I Sample Type:.
Repeat Test? (check one)
I`10RJA1 ;7C 'SON- METALS (mw/0 MICROBIOLOGICAL (CFU /100mL)
nC_—y
Al: alinity
Chloride
Detergents, MBAS
Hardness, Total
_ Nitrogen, Ammonia
Nitrogen, Nitrate
Phosphate, Total
Sulfate
_ Sulfide
Sulfite
METALS (mg /L)
Copper
Iron
Lead..
-- Manganese
Mercury
Sodium
Zinc
MISCELLANEOUS
PH (units)
Color (units)
Odor (TON)
Turbidity (NTU)
GENERAL BACTERIA
r\ Standard Plate Count
(CFU /1.OmL)
MEMBRANE FILTRATION TECHNIQUE -
Total Coliform (�
Fecal Coliform
Fecal Streptococcus
140ST PROBABLE NUMBER TECHNIQUE
Total Coliform Index
F -.•cal Collf.drm Ind -ex'
KEY FOR TERMINOLOGY
N/A = Not Applicable'
LT = Less Than ( < )
GT = Greater Than (>)
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
NR = Non - reactive
REMARKS /COMMENTS (For Lab Use)
Potable
_ lion -rotac
_ STP
_ ST?
Other:
Sar:p'e Stat..
(check eac '
Out aoin:
— HNO3
H C 1
H2SOL
NaOH
ZnOAc
Na2S2O3
Other :
Indominc
�.LEE
4 °C
GT
4 °C
_
DH
LE 2
_
P"
GE 9
_
p:.
GL 12
_
Other.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS ") (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO T N YORK STATE DRINKING hATE�
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
THESE RESULTS INDICATE THAT THE WATER .SAMPLE (DID) (DIDN'T) (N /A} MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA D NKING WATER
CODES, FOR TAE PARAKE;SAS TESTED, AT THE TIME OF COLLECTION.
2 /86(Rvsd7 /87)RWE
Albert,H. Padovani, M.T. (ASCP), Director
I \j
V.
This is to certify 0that I have s,r,,,,id , B E N D E V I N 0
9S, LOT_ 8 91,E ?, q 4- �
I�P rivylv4YOR0
— toF�ISIE PLA
A
MT. VERNON. N. Y.
PPj+navn %ICL Ilel cauent4j, of AA VW x VI&- ROOM 233
TELEPHONE MO 8-0880
Filed in the P.4nct,•.i County Clerk' s:Offic.e Division of Land Records May VW t a t. zCI as Map 186 6.
I have located all existing buildings and lines of.possession and have shown their positions hereon.
I hereby certify this survey to "'C.'
Survey completed: 10 Ick-I -L on scale of one inch to 20 feet.
Map drafted: $A-.& w, 15l 2 N.T.S. liC. 36170
stoke
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Palo
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5fKP
0 A000
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Guaranteed to..... / C.
in accordance with the minimum standard's for title survey's of the New York State Land Title Aasociation.
.. _ .:PUTNTv�'.( GOIJNTX4 NF�,�Tu..1?FP�R'.?A�':.k -:: �. �, .,� <. � _ . 4 .. ..- , . .. C- .. r�- •�
DIVISION OF ENVIRONKEMAL HEALTH SERVICES
John Me Simmons, M.D.
Deputy Ccamni.ssioner of Health - FIELD ACTIVITY REPORT - Sheet Q of
N � KREM INSPECTION
NAME Orig. Routine
J. � Ve _ Orig. Complain
ADDRESS H® B ro o j�P Origo Request
No. Street Town TM No. _ Compliance
Complaint Comp,
MAILING ADDRESS Final
P.O. Box Post Office Zip Code _ Group Illness
Construction
TELEPHONE
PERSON IN CHARGE
OR INTERVIEWED
Name and Title
DATE TYPE FACILITY
Reinspection
Field, Sampling Only
Field Conference
Other
TIME ARRIVED TIME LEFT .° o ej Explain
FINDINGS°
e
INSPECTOR: TELEPHONE:
-r—Signature and Title
PERSON IN CHARGE OR IRl'PERVIEGdED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE: