Loading...
HomeMy WebLinkAbout0725DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23.13 -1 -12 41000.j 00725 1 INN ML I �I '� Tai. 1 �' , !r ;� is -- ': IN IN IN + IlLo 6, IN I.. IlIk IN IN IN ' 00725 r' LORETTA MOLINARI Public Health Director 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 December 17, 2004 Barrett 3 Deacon Smith Hill Rd. Patterson, NY, 12563 Re: Addition — Barrett, Deacon Smith Hill Rd. No Increases in Number of Bedrooms (T) Patterson, TM #23.13 -1 -12 Dear Mr. Barrett: ROBERT J. BONDI County Executive I have received and reviewed the plans for the proposed addition to the above - mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated December 16, 2004. The addition is approved with the following conditions. 1. The total number of bedrooms must remain at three without prior approval by this Department. 2. The area of the existing sewage disposal system, and its expansion area, must be .maintained. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc. Any permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Patterson. If you have any questions, please contact me at your convenience. Since�reely,p Michael Luke ML: ]m Public Health Sanitarian cc: BI (T) Patterson ' o l� DEPAR i MEIv i 01P I-MALTli DIviaion of Ensiremrnsental Health - Ser -ices 4 Genava Road Brewstar, New York 10SO9 Tel. -0114) 278 - 6130 Fax (414) 273 - 7921 "M W 2 L • BRUCE R FoLBy Public HeclM Direvr -, S 'REST Wei T vi AP Ir NAME � r PHOr'E �� " f. �t'trl'CHD r MAM a ADDRESS J DESC`.R PTiON OF .A- DDiTIO?d NUMBER OF EMST -TNL G BEDROONLS (FROM CERT. OF GCCIL PANCY OR CERT1FtCATt0� F?13M SULONG I11SP£CT03L) �y PROP# OF 13EDROOyLS� *Any ;dditien wxhich is corsdered a bedroom iequires formal approval of plans (Construction Permit) prepZ-Pd by a - rcfessio: al Engineer or Registered Architect in accordance with aoplicab:e sections of tht Punam Co:znty Seniwy Code. Please submit this form 2,:;d ?he fo'lowing to Putnam County Health Dept.; 4 Geneva Rd., Brewster, ;1Y 10509, Phcne 2'S -6? 30. 1. Certified-check or nlor_ey order for 5100.00 Sketches of existing floor p;an (dawn to scale,, all living area Including basement) * Non- professional sketcn._s arc accepuble 3. Two sets of proposed Loor plan (drawn to scale, with name, streea, a :d taz, rinap T) * iron- profcssiorai sket,hes are acceptable 4. Copy of sla vey showing well and septic location, to the best of your kawledge. Include date of ins?all-atioa if town; Label all `ells and septic systems within 200 feet of the p:operty lane. Contact this office wi-h any allestions. 5. Copy of Cent. of Occupancy from Town or Certifcatioa from Building Dept. Nith legal bedroom court of dwelling. OFFICE US commen7.s z-.b va" 9RUCE R._FOLEY, H g Aetlnp PUbIle Nealth O��e :tar DEPARTMENT OF HEALTH Division.-Of Environmental Health Services 4 Geneva' Road, Brewster, New York 1o5o9 (314) 278 -6130 Putm County Dept. of Health 4 Genova Road B:ewsut, NY 105C9 Residence �j✓ Tax Map � 3 • % 3 :Z- /w Town .e_ . Yll _ Gen men- According to records maintained by the Tom, the above noted dv elli'ng iS :S iJ0 T in complian:- N,, ;th Tov ,;. code and the total number of bedroom: on record is This infoi7:lation ;gas been obtai.-2ed from: CERTIFICATE OF OCCUFA2�CY: ASSESSORS P:ECORD: () HER zw' Building inscector St �r Co 9RUCE R._FOLEY, H g Aetlnp PUbIle Nealth O��e :tar DEPARTMENT OF HEALTH Division.-Of Environmental Health Services 4 Geneva' Road, Brewster, New York 1o5o9 (314) 278 -6130 Putm County Dept. of Health 4 Genova Road B:ewsut, NY 105C9 Residence �j✓ Tax Map � 3 • % 3 :Z- /w Town .e_ . Yll _ Gen men- According to records maintained by the Tom, the above noted dv elli'ng iS :S iJ0 T in complian:- N,, ;th Tov ,;. code and the total number of bedroom: on record is This infoi7:lation ;gas been obtai.-2ed from: CERTIFICATE OF OCCUFA2�CY: ASSESSORS P:ECORD: () HER zw' Building inscector e3• k rule, e-.. C57 1�,r�bo�e, v �,n, 13/W� PUTNAM COUNTY DEPARD IENT OF HEALTH HOUSE PLANS APPROVED FOR Ste' "�'� �r�°� BEDROOM COUNT ONLY, 27' Sktatute A Tdle Date y2 1 Lim ry 13 l%�ccJ.� ����'� �, •// ice! jorn 4 . lr�l n t Pl,TNAM COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY; BEDROOMS 0 .Scpature & T"dle D Ye ,101/ r �a u,cro�ry j���o�� 1-✓ �/% -try C- l�Gtr�'e%� r �b,'/ 'a7PeA ZFA ���� ;, �:...� :.:rte - >::•_ ��n^t.��''. - :���::.:;. - .6.A.'•;�rsii ^•YJ'�'�..t.....i!:�Y% ,._' ^'t41�a'�iy:': %�. �i \. ; }�'.' � .....�99:Y �F lip : �rt�;' :s� " S~Yl•.j4,f't�r 0�`,+tv�'.l. ;u,u.:�t' / ^'4iJ'•" : �, � X71 � � iry � �ki�a���.''. 'G'`�' :: •.. tS �gM:' �8 � � ' �(� .'•1��� , a apt �r��-�r k i c �i tC{'�zr L" 4 6�. �2' c G�,�t '•,"fit �"f,�i}( �``� •° 7►�y� t y. +4'�A � y'Y'+'�• J s K i \� �� 1� '� i 1 �s � {e r e \tiiw'�� t �T'Z � ;Jt* 'a��':Nk JL •S. i. :.`r; �+�'a ?,)}r`r Y.�,,i \: / - ': °_`�:d F; "' Sig' ::�'•'•n'�''a=.:= °:i: . :O %.�`•/•' W-1 . N�•,y •y-i ,1 ,k 4 ~;a A L C •n f <it c jk LLi 'r. Mkt ,.; ti •'r :' •. '�': flp ��� 0 N iz e :'t :�': �;t•• Vii'• y.. ..: �'}ij, ;fit .jy.3 _•: <`ti� "., "•J;`i,," Vii` • � af.'•t r..;s+.•,• �. •Jr�?rA r X't °yw• . "ifs Ou �'La y���,'� t` k bt its. n,;, •� .�,;; `�.': •'� �� 4a .•},aft C F + Y �Y Y 1 l l .•1� � 1.. RS Y r _ ' t � f t k L t� PUTNAM COUNTY DEPARTMENT; OF HEALTH f Division of• Enwronmental Health Services, :Came% N, Y.:;10512 CERTdFiCAT,6'OF CONSTRUCTION COMPLIANCE JFOR SE WAGE DISPOSAL SYSTEM 772FZJ'QN .Town or Village Located .at %���'C�/l/ �1 �✓%l1'/� i %�'�© .Q%� r Section Block �A%'U;G Tom.: ` ��ie'''� TT Owner Lot . Job .. Z Separate. Sewerage System built by Address i - Consisting of, Gal. Septic Tank �� rT lineal Feet _X%`" width trench, m . Other, requirements Water SuPPIy ' Public Supply. From i_ Private Supply Arnlletl BY r `Adds /ess; r' y YC�N�;O Building Type No: of Bedrooms Date Permit Issued :Has Erosion Control `Been Completed " �` �� R # t I certify that the system(s),as listed serving the above premises were constructed essentially a shown on, the plans of the. completed work (copies of which are attached), and in accordance with •tha standards rules and 'regulations plans filed ah permit sued by' the Putnam ,County Department of Health. Date Certified by P E R A. r h �jr �J Y,. . tO 5i .ilr/% Y Y d � �"�j ` License No. ��� C s� Any: person :occupying premises served by ^the above system(`s) shall promptly"take such action'as maybe necessary to secure the correction of any unsanitary .conditions resulting from -such -usage ;;Approval' of the separate sewerage syst6ir s' all become null,and void.as,soori as.'a public sani6iy sewer.beconle§ availableiand the ;approval, of the: private, water `supply shalhibecomernulland. void when a +pubUC water supply becbmer available Such approvals Are ;',.subject;to modification'or " chanje when;. in the'judgment.'of the.Commissioner of Health 'such'avocation; modif,icat�on`or change, .is necessary - ;t CL :. � rF ., �.. - ,..Ua...w ^' �. .mow -�,- .vc ,•a -.ems a' <.`. ILI DATE COLLECTED .RESULTS OF EXAMINATION OF WATER. OWNER in rtnt.civcu CITY, VILLAGE, TOWN & /OR NAME OF SUPPLY: DATE REPORTED- .. 1 SAMPLING POINT BACTERIA PER ML. (Agar plane count at 35 C). J COLIFORM. GROUP (Most probable No. /100m1.) Q HARDNESS, TOTAL - ppm DETERGENTS - mg NITRATES (as N) - Ipg j,' IRON, TOTAL - Mg /L AMMUNIA, extx (as N W mg /L These results }indicate that the water -w was i/ i� of a satisfactory sanitary quality when the sample was collected. A. H. PADOVA I, M. T. (ASCP) 0 0!1rvtb A daao n r�e�w o POT NAM VOYN Y KIP�I�i X79 /� Divia►pn of EAvir9nmen pl Heplth rmrvWp CPVNTY QFFIGF PWII,PINQ - CAfIM94, NOW V9jjK TWO FOPP.0 1114 10 I- ImpI.00 OV W911 driUar ON 44bmitteq to OgpntY Flla�lth pep4rtment t9 pther with I@Iiipra�vey PQliarl Qf IIRgjVI AermPle indicRtln� water Ie of b�tit#faCt4ry b�clteridl g4lality bgfQre cgftificatfj Of consitruiwtipn Ia1IPliotl I@ I6alf, REPORT MUST BE SUTOMITTED WITHIN 30 DAYS OF WELL COMPLETION Hal. Barrett Deacon Smith Hill Rd. Holmes 6; two. Deacon Smith Hill Rd. Patterson 1 Fi1�PaT ffii'is1 I ;IiTI OT4414MMFMT f,-) FtAR €9T 1N PUR419 AIR OTHFR PARRY I,,. ! INQU #TRIAD t .i �IQNI?ITI{rlll?!O t. -J t:pactfy) C LAIIdt11 ca,0i°r it t^7 (''j COMPR@SSED CABLE OTHER 4.,1 RpTApv UU AIR ?9KU38 ►QM 4-1 REI? US�IOM D (5aatfl') CASING GQT� y Th(� 41A TR(Inchgsl 20 6 %Yplp►1T rep FQQT 1:.9 . ((- �'^� I .� TI4t;I AD L J YdRAIOEP Yi;B NQ Vill top TR8 4 . Imp � P�4FI!AI ICJ �QMP��$�tp ,p ►Q 2 6 V140 M.P.r�,� 6 tiiATO Lr � MM 4110 PIR 18 N4 glgM 7451 [IaFU total drawddwn Uppth of Cpmplgtod Well In ft+ot 4algw Land Avrfp ps 200 " MAIN Rte..... WHOM QPea TO A 4lIPAQ Ife'�f $ 1 P IVMTER (Iacha Of well (, plpmeter tns ludin� FACKV, prpvel pa. (Inc GRAVE 1?4) F 4744a vf 11"Q U 6 ,,;; vQQA 1AQ ousp A FORMATIQN foA exact location of ryf/ with fetapFAa, ►o of 4908% ¢o nporenent ladmPBGT A!kp, to QtT 0 6 overburden iyd Arkegtn W01 Co., Inc. R. D., 5 - Rout 52 Qarmel, N. Y. !Q512 6. 200 ledge If 0404 ;,4; faytotl a! ampr9ni tba during 4riQin , Iift Ixalt+w E3$ "UONS PER MINUTE A fMOfItTi<lT 6/.1.2/78 1; gl'O'AT 6978 M1�L4 ()RI ... -... gnAtHCd) ry Atio Pt17'itfAAJl. 7 H15 SEP 16 197t" IUT Y PT OF KE�il2 REVISIONS, ' OF y , ",'�: GEORGE A. HAUGHUE1(, ti✓ CONSULTING ENGINEER �2 — 'Carmel, :New York 1(3512 ... ... >y�. DRAwiN NO.: ' � � � _.�... •.: .. DATE _ •CK D. •BY - ��• �: " ST!'N Oar a ..,•...... - °. qCY4 �..x x 2 8 ' T... _ 4_ f r !F �., �) -6 4 '27 -•, - x :v 04 Atio Pt17'itfAAJl. 7 H15 SEP 16 197t" IUT Y PT OF KE�il2 REVISIONS, ' OF y , ",'�: GEORGE A. HAUGHUE1(, ti✓ CONSULTING ENGINEER �2 — 'Carmel, :New York 1(3512 ... ... >y�. DRAwiN NO.: ' � � � _.�... •.: .. DATE _ •CK D. •BY - ��• �: " ST!'N Oar a ..,•...... - °. r ' , i PUTNAM COUNTY DEPARTMENT OF HEALTH_ d � .. ' ¢ yt. ': Division of- Environmental,' Health Services, Carmel,:N. Y 1,0512 CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL $Y TEM Town or Village L' od at . d ' Tax •M cate ap Block Subdivision 'Lot Job Owner Address �S �• , Building Type; Lot Area _ 0�•'. Number of Bedroom SL s _R Design Ft Total Habitable Space � Square Feet. Separate.Sewerage System M. cosist of 10 Gal. optic Tank and �+• To be constructed by Address Water Supply: ` Supply .From, Ir Private Supply to be 'drilled by Address Other . Requirements I represent that 1 'am wholly and, completely responsible for the design,and locatiori' of the, proposed system(s); :1) that the separate sewage disposal system above described will be constructed as shown on thi'Approved,amentlmentwhere, to.and in accordance with the standards; rules an regu a ions o e u nam y hat on completion thereof a Certificate of. Construction Compliance" satisfactory to-the Commissioner of Health.will Count Department .of Health and t be submitted to'the Department, "and a written 'guarantee will be furnished the owner; his successors; heirs or assigns by the builder,. that said builder will place in good, operating', conditiom.any. part;. of said sewage: disposal.system duringthe•perio,d of two (2) years'immediately, following thedate of the issu -. Nance ".of the a . approval ,of the Certificate',of. Construction _ Compliance of the original system or.any '- repairs thereto; 2) that, the drilled well described above will be located as shown on the approved plan and that, said. well will be installed. i cordance' with the standards; rules and regu a ons of the Putnam County Department of Health. Date 5 ed P. E. 'R.A.. Address ' License No. APPROVED FOR CONSTRUCTION This approval expires one y r.from the date issued 'u s: construction of the building has been undertaken and Is revocable for cause or may amended or modified when consid ed ecessary',tiy .t e� -Co,m ' sinner of Health. Any change or alteration of construction requires a new per it roved' ed' fo ' isposal of "domestic ^sa star`' age pr e ;y� 76-L .� Date B, V Title • rxrr,D CTrEM" I ST • Insp. by INITTAL SITR 111SPECTI071. 1� -` /A Ycs . No Comments ,Property lines or corners found . . . Can cstim..tc hou �e location ° Will. driveway need cut Ntu t tree- be removed. -note these . ... . . Is deep hole representa-tive of entire SDS area Additional deep holes needed. . . _ Sufficient SDS area available considering; driveway cut, house location, separation .distances, etc. . . . . . ..'. _. -� -- DErP HOLD DATA -Water elevation: Rock elevation: Soils d.C' C1':I.,atl0ni~/& Date. FINAL SITE INS.PE0CTT_OV Insp, by House located where shot ;,,n on approved plan _ SDS located where approved . . . . . .. .i.on�th of trcnch measured Width of trench average Slope of tile line -and trench acceptable ... . Doom allowed for expansion trenches . ... , Over .50 ft. from swamp, watercourse . . Natural soil not strij5:u d - or SDS area - tuiriecessarily graded _ 10 Ft. maintained from prop-line and 20 ft. from house Sepggra.tion of trench from house, well etc. follows plan . . . . . . . . number -of bedrooms checks - Stone:, brush, stu ,Ips, rubble, etc. greater than 15 ft. from nearest trench . . . . . . 15 IL- of peripheral soil horizontally from trench . . . . . . . . . . . . Junction boxes properly set CoW.d surface run off from driveway, roads, ground surface, etc. channel no- ar SDS . area . . . . . . . . . . Does l.ot drai_n:e a.t p -ar 0. K. in area of SDS FINAL GLIDING OI'' SITE ACCEPTABLI PUTNAM COUNTY DEPART EI T OF IIEALTH DIVISION. OF ENVIRONMENTAL HF -ALTII SERVICES COUNTY OFFICE BUTLDING, CARMI?L,, N.Y. 10512 DESIGN DA A SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM. FILE NO.' owner r Address Located at (Street ec. Bloc); Lot / n i.ca to nea- e cross s ree Muni cipality��"i9b Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMIT ED WITH APPLICATIONS 2 3 4 5 2 4 5 Notes: 1) Tests to be repeated at same depth until aoximately equal soil rates are obtained at each percolation test hole. Afl . pr data to be submitted for review. 2) Depth moaasurements to be made from top of hole. Hole Number CLOCK TIME PERCOLATION PERCOLATION Run Elapse No.. Time Start -Stop Mina i.—,eptri. to 1,,-a From Ground Start Inches ter Surface Stop Inchos water ' ve in Iches Drop in Inches Soil Rate Min. /in drop 3022 - J A2 /0 0l 2 3 4 5 2 4 5 Notes: 1) Tests to be repeated at same depth until aoximately equal soil rates are obtained at each percolation test hole. Afl . pr data to be submitted for review. 2) Depth moaasurements to be made from top of hole. TEST PIT DATA RiEQUIRED TO _PE SIT°3P" 17TIM WIT}I APPLICATION DESCRIPTION OF SOILS TdCOUJ�'.['.r;P,F,D IN ''i'1?`>�I' IiOIu;S DEPTH HOLE. NO. % HOLE NO. HOLE NO. G. L. 6" ;18" '{ ;; . ;. 3611 ?I2" '4g" r, 6o" 66" 7211 .78" 81+ rr . INDICATE 'LEVEL AT WINCH GROUND WATER 13 ENCOUNTERED :! INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTER.E'D' TESTS 14ADE BY mil. Date. _ DESIGN Soil Rate p '� 000 Use ° / Mir�/1 Drop: S.D. Usable Area Provided�J . �'..:• No.. of Bedrooms Septic Tank Capacity Gals.. Type �GZd Absorption Area Provided B L.F. x21+" X b"— width Trenc 1 . , e 0th r ame gn£a ure Address - SEAL:�'````��5� TNURbp'''"p., c� %R •; THIS SPACE-FOR USE BY HEALTH DEPARTr,1PNT ONLY; Fo "moo ;, Soil Rate ti p4g8�•• .Approved Sq. Ft /Cal. Chocked by p�-- Date , J a C ro s'r t tR tt tt yk ti•; 5 ,� r +. ",, ° h"f: ` - # + '� � J � k ` � r j $ � �,� _ J i\ S' •r �r 'r °" w 3 f c> * , a y e$r F If' YN L i '. t .� a t, .. i r r.. � "'! 5! �� o `� r r ,,:,Y � � c\ r�i °• n- 1 4 i1, "� n Y br f/�� Y& Y5s a r\ ast h t J A y yNM1 rx h 1D f •� t _ k' (, 2 t�,} is •rt kt a t -t i�. � J : r Jr � �'" 4 a , F � +a r` f �'r+R taa � t .c a.5 $ hh +ro '� { �. y c r�ryy n� }�Ji + {r r ���`�Y r+-.`57"dj r r r' 7 ,}a % '`'' 4 '• +� t,. 5t^N'.r Cas "," I A " �' %� { 4 e�'ts a` Iwt o �. �' C• t r4'J,ty+ yas,T u.. ,R 7r <''N"vi �" t j .^'f R� 2 �y.. 3 � y Sr ,� - � t n n i r alYrr �k '. ' v' i',� �.e :r '+ r '' f�� R r �' Y' � �i'4� � •�} 1A .1 T .,f' ".' �,V'q'.xc { Pry i` �t arl' 'Y �""� tri' +.� r t i.` h '. tRt yy .r u�n y d ar i}}� \o�, iyf ��fk'4 •r rrbr /r 1Ir} stt T'" f} `1• ar.7 e a tin. t '�! � ,� r w a k Rxt�r A 51 ti 16vt M r tt fir• r �..a r aY �,,, ate„ x�r'+41t r. r°rjJ v !• r yy l i r t ;� ,yy��7N'�,�r�g 4 �•a,c i „ �Y ._ y a �� kpX�e� a� ? � ti3� d� F� � r� �� t. Sr t� A� /. ko lw ,:yY j� .' l •{ i:.: \ Y � 1..� t� fl l" ,yr t .5. Y E .� P P } \y ,�'�1 _ 11� . 1 wt Air i' n t � v a t )! '� P t 5L YP �d'k R '��,• � L � \ k }4j r �i w v9° 4��� ry J } r �l �r x` �• �i'§ ai w r t v xyk ` ; x X, U. �} t, t. '� d 2 R; i,� �A� Y y�5 d dui t <iY�a ` ti S:t U5g ✓r'W�'r fr ``i m�� d 1 t ssv I, 4L1 1 %,,,, � "'f 11 t Y Y Y S ! 3, 4rEr, 611.1 ti t �l � w 'r r~ +4 H ,^r"a ' 1 �.. '. � J Nn g r tJ a tYt r y ! r' 's'4r : 'c + ws n r r 4 � t S+S S �r f titi � ,. r >• N x .o 11 e° �t i+" i,#. , ..a tix{ i '�:.1 t�1 vd 'A r A � & { ; e n\r � y., J y OR N1 I JJ �y)� �y� J '�` ') t � t t.r 4� � \, �d• G,l�i�` � � \fr� �Y, a A F N i Nya'at N a s 7 i a,r tv fi`ay YId'N�xa f ent t � t yy777 4' ,fin 5y rtrt`iy°,t ag, (� G+ t" P H' yid. �illF•F Y i �p i k�7 n,3� � �� ,.,C ...fi •1 � � �' _ s °. „ � �s,f •�.y �l hf,M f��.3 ZJ1`7, r..5r ripJ s i? k '� k t{" r.V r N r `r �i.11 ta17� IV` 1" '�`.. of 3x ^ � i !M r �� ,•�fi �wti r"` �t�� w , /r �Q'C P - r t art i v ^ib u fi iAv {i.. i yi ''"'� F i f � t �F -!dS, � {,� 7 ♦ J,1'.�j C rR Fr J ,�\" � t k' F� �' a1 k, I ' f S v qq( t i, � ��."1, �.•� Jv "Yil� :� !±��� �.: �, r .. . � ':. , y 7 � .'r$ {t rt :'. dd V `�w`x .!4�: +� nr�ltN,t �,y: ,bT.+.,.. ilnE,�„ ", ►►°° ' K r ��� 58 L AM' v r kn it 4 4x 'aR "yy,..JrP+yyV.rr j sy Z iEry vK a'. \ . �w:. 9t Jh �f�^ ""K Y: ' � •� r r � �Y., x�(k � 1. k+* J �fYe,f �Tr`^•+MrY *'P��T`r t. /r t i 4 Fes, , c t 9� v iann -r ! � \ r a ;, Ii r ,sY� r-,�"r a 4' � ^.Y M ., n$ } ri � • , p, ,.: "; fk� � � 'tAV.aq r ' S } 4 J k z, r � S CK- PUTNAM COUNTY DEPARTMENT OF HEALTH o D DIVISION OF ENVIRONMENTAL HEALTH SERVICES 1G ta - 1 APPLICATION TO CONSTRUCT A WATER WELL O&N, please print or type PCHD Permit # (k) Well Location: Street Address: Town/Village Tax Grid # -�i . �_ Block Lots) Well,Owner• Name Address %� Use of Well:_ Residential PulRic Supply Air /Cond/Heat Pump frrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served _9� Est. of Daily Usage 95 )gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) W Deepen Existing Well Detailed Reason Z44) 114gh4 A244= 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 Name of subdivision Lot No. Water Well Contractor: 24ag ��iz/,�f%/-..L IA. Address � , 1 Is Public Water Supply available to 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 pro ided on sep ate sheet/plan. Date: Applicant Signature: 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. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water a driller certified by Putnam County. Date of Issue �� Permit Issui O Date of Expiration" - d'-1410 Title: Permit is Non -Tras rra le White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97