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Home My WebLink About0972DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.46 -1 -2 BOX 10 E 1 00972 • a� pirlitt or We PUTNAM COUNTY. DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL P , IINNOe m-'it1 9f 5 w: , Well Location - Street Address: Town/Village: Tax Map # 7 ,Q Arc 4 p r i G a� a .S o v Map Block Lot (s) Well Owner: Name: Address. Phone #:� /! �Ct�pt�A,v g Q �/ 7 to /Veks bttr RCIr I C{IlL d�.�� Lt9�- 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 _5:- gpm # People Served Est. of Daily usage gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason a for Drilling c r Well Type ✓ Drilled I Driven Gravel Other Is well site subject to flooding? Yes _ No'w Is well located in a realty subdivision? ........................................... ............................... Yes _ No+" Name of subdivision Lot No. Water Well Contractor:- a r hakv k%aerson Address: Sf- u�-� -,4 Is Public Water Supply available on site? ....................................... ............................... Yes _ No k/ I 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. Date: 2 Applicant Signature:_ .,, a/,(Q 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 Deoartmei 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 Commissioner of Health. 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: Date of Issue 3 Permit Issuir� Officia . zz� Date -of Expiration Title: �i/3S�s /�C" Permit is Non- Transfeiabl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06 JUL -12 -2013 12:06 From:FGI CORPORATION V1 r SJ .s 7Z --r r RECEIVED 06/04/2008 22:31 To:1845528149O FZ 3 2 Page: 2-2 r l �r IL DestMon: YVPR qA AM PurWose upp "Me docunrenta meat Pool. etttchad): - _ / % • �... An t- lowing aecdOns'DjUgt be comWeted snd sub ftd bebm any i MMIL Couatlt Executive A): County Vehicle Requested: _�.Yss --Y—po Car Appnovvtl: B)• Travel rce uessaa: LlMil +� • O mom r WO PAM N&MLLS" .AO�AElE • 91l8flRA1Nf1'Alp'' � ?� , ®7? TONAL CAR a� RE018TMWN FEE '* TBLEP 10119 CALLS'" Mr TOTAL Cj: Llat these pab rap" siblil�es which wilt be mMsed during absence and Irtdlcabe arrangamente: D); Employee Slgnatuve:P�1 41 A A =2 Data: jev.fS___ E). Appmp*Ons: l 10 —6r�Yo L - TMW Amount Budgeted for Department $ ifoo Travel Amount Used to Date by D ®rrt $ Department Hea&Eiecbd Offt Date: � County Executhn Approval: 6 MOW `I MbMt Rem do 1, WAD RrwW V $7.00 Lunch/ $12.00 Dinner •• AU TetaQtdone csNs moat 6a far oAlah•) t?utnam tnxmDteee • "• Receipts rsWW as vM as i(teraWre an conftem eh Wng registration costa B4 4 From: Brian D. Devine [maIko:bdd0;@heaN Sm b WedneWay, June 19, 201310:14 AM To: Wafter Dawydiak; James.M ffAm n7suffofkcountvnV.Q0V; Mark Rothstein ; Don Irwin; Angela Petinelli; ci"heafth.nyc aov: fim1*westrhes4erXggv.00m:Judy Hunderfund; Ed Simms; John Score; Robert Morris; Jim Fouts; bdAQdutchessriv.aov: lhuanofDhealth.nyg -M; Shelley Mertens; Michael J. Duffy Cc: Christine A. Westerman; Seth L. Schild; trnsOB(d►heaith.statenv.us:. Michael J. Cambridge; Nathan M Graber; Claudine Jones Rafi'erty Subject: Drowfng Investigation Invitation : July 11, 2013 Dear Directors: The NYSDOH Metropolitan Area Regional Office will be providing aquatic submersion Investigation Training. The training is designed for experienced Swimming Pool and Bathing Beach Inspectors to conduct thorough drowning or near drowningInvestigations. This training Is designed to give the inspector an understanding of how to conduct a submersion Investigation using our. drowning investigating tools. The training will cover contributing factors to drowning how to conduct effective interviewing, Inspection techniques and producing final written report. The date, time and location is: Drowning Investigation Training _ Thursday, July 11, 2013 10:00 am to 1:00 pm NYSDOH Metropolltan Area Regional Office 90 Church Street, 4th Floor Conference Room 4C New York Nlf 10007 As this venue is restricted to 25 individuals we would appreciate if you could send a list of prospective candidates M order of priority and experience. Please send a list of names of staff who may attend this training to Christine Westerman cac11 @hea1th.state.nv.us and Seth Schild sIs1741health.state.nv.us by July 5, 2013. We are required to provide a list of attendees to building security. If you have any question please contact your field coordinator. We hope to see you there Sincerely, Brian Devine, Dliector Environmental Health NYBDOH MARO 50 forth St Montiodlo N.Y. 12701 Work Phone: (845) 794-2045 Mobile Phone: ( 518) 396 -7157 d PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'l PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWKMIS NAME SITE I=TIM PHONE 20 MAILING ADDRESS �S'A �1i? PERSON INTERVIEWED ($ w ti X PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FXILITY re PROPOSED INSTALLER PHONE 91y -OS =3S 73 REGISTRATION # U le f�-C'- Proposal (include sketch locating all adjacent wells): 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. T„ /r Ds %l - /I II I all U Ida 'Ah; Fz.r e Q, Uosa1_ --A - - Proposal approved Proposal Disapproved Inspector's Signature & Title Date roposal approved with the following conditions: 1. 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 canponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, r agent of owner agree to the above conditions. SIGNATURE TITLE DATE Cz� i' : Wiite MV; Yellow ('j= ED; Pink LzWli®nt) Dr-DD 07 I ,� I -5 r r . 'I ` . ` L Lo i ilw � 72 K_ w ��n . .��+��► _ four. _ ► ► i i i it � � ! ! III t t L -J- � _ � k k � �-, . . �. I I I I I I � � ► ► k _ � k i i UP � L L I i i-" A PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONAIENTAL HEALTH SERVICES, INITIAL 'INDIVIDUAL ADDITION REPAIR FORM. SECTION A. GENERAL INFORMATION Name of Project ' Year of Construction Size of Parcel SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. ❑Rolling ®Hilly / Steep slope n Gentle slo,pe ®Flat 2. ❑ of wetlands Clow areas subject to flooding ❑ of water ❑ ditches Clock outcrops YES NO 3. Property lines evident? 4. Water courses exist on, or adjacent to parcel? ❑ /❑ 5. Existing individual wells within 200f1 of the existing SSTS? /13 ❑ SECTION C.. EXISTING SUBSURFACE SENVAGE TREATMENT SYSTEM (SSTS) 1. Physical character of existing SSTS area. A. ❑evel ❑ Gentle slope CISfeep slope B. ❑Well drained ❑Moderately well drained ❑Somewhat poorly drained ❑ drained C. Area available for SSTS, (Primary. & Reserve) ❑ limited Somewhat limited dequate ft x ft D. INSPECTION Date .S '� Inspector Mo evidence of failure IlEvidence of failure % DEvidence of seasonal failure - ----------------------------- ------ (Indicate North) m �Y HOUSE NJ ------------------------------------------------- - - - - -- (1) Indicate location of SSTS A. Size and type of septic tank gallons ni'vietal Concrete . CIPlastic B. Type of absorption area 1. Fields ft. 2. Pits 3. Gallies (2) Indicate tetbacks font street, bacxyara; and side yard duimeas oris (3) Show location of well . (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams/wetlands) SECTION E. EXISTING WATER SUPPLY MPWS Cj Shared well Mindividual well Amur rut Drilled Mug C1 Casing above ground CON% ENTS