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HomeMy WebLinkAbout1153DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.56 -1 -80 BOX 11 01153 IN.- :l';0., ��. rr Tr1� 'r �r . .` ti . INN 01153 IN.- :l';0., ��. rr Tr1� 'r �r . 01153 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES ��Q -fn YES N Intemal Use Only PERMIT #I -1 ` " - ' ❑ r.W Repair Permit issued in last 5 years ❑riot in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION IGg L&Nt, n TOWN TM # �j,5 ;. •� - OWNER'S NAME tlk C C, 5., n ; PHONE # MAILING ADDRESS lU 0 ICJ a. gyX ..rcl`✓',� [ `� APPLICANT Cui-, ,w, Name & Relationship Va., owner, tenant, contractor) DATE r7= 11,6 1 0 FACILITY TYPE PCHD COMPLAINT # j PROPOSED INSTALLER '�?�n (5; PHONE # YC-? ADDRESS 7 C;r. c..z, i�. .✓/r REGISTRATION /LICENSE #G�� — Pro sal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the I, as owner,agree to the conditions stated on this form SIGNATURE (owner) I, the septic it SIGNATURE pnstaller) / TITLE D DATE l I L l , agree to comply with the conditions of this permit for the septic system repair TITLE / /7n DATE 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Pr sal Appr Proposal Denied ❑ I pector's`$lgnature &Title Date Expiration Date Repair proposal is in compliance with applicable codes Yes O No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 AD Gat, P/ i; 21, a : `�• f" i' N17 F/ F, MNCr 4 \ W. 2y, f% i C� IMNEY Ir --6.6 nil MAC vv�lvr, Dec 07 10 12:14p Putnam Lake Fire Dept 8452791364 p.1 OEC- 08.2010 12:48Pq FRO*- MfRON,IENTAI REALM P.001 /001 E:-60i �> PUTNAM COUNTY HEALTH DEPARTMENT ul U �IMSION ©F ENVIRONMENTAL HEALTH SERVICES �► THIS IS NOT A RF-PAIR PERMIT MOPOSAL FOR EXPLORATION OF SEPTIC STEM FAILURE All information below must be ftl completed prior to any scheduling SITE LOCATION 'OG ` �, /SC 5�,�2 TOWN 09 �'''� TM # OWNER'S NAME PHONE # MAILING ADDRESS -f ./y- PROPOSED CONTRACTOFMNSTALLEA PHONE # ADDRESS 7 (i'C''"C �ih �L�-- REGISTRATION 1L'CENSE # _ fie, fy- Reason for exdoration: O failure to surface 0 'back-UP in house 9//find limits of system for repair C1 other (explafn below) n ,:9 .e F" A77715 FOR COUNTY USE ONLY Date Appointment Cate: Time: kly: excel:5eptic MEMORY TRANSMISSION REPORT TIME DEC -07 -2010 12:32PM TEL NUMBER 8452787921 NAME ENVIRONMENTAL HEALTH FILE NUMBER 626 DATE DEC -07 12:31PM TO : 82791364 DOCUMENT PAGES 001 START TIME DEC -07 12:31PM END TIME DEC -07 12:32PM SENT PAGES 001 STATUS OK FILE NUMBER : 626 * ** SUCCESSFUL TX NOT ICE * ** X3®c 07 14 12= 14p Putnam L+ea icv Fires nvpt H452-79:L::i p. 1 0EC-00 -2010 12.4$PY PROM- VWFRMUMRTAL HEALTH P. 081!001 "GOO Pt -rrN^m ocniu r 'r v H m^L-TH dSPARTM�NT D1VFSfC3N aF eM%nFtClP~F- :M-rAL HEALTH ZMM%nCES .IS . AiOT .A Ft>EPAIIFR PERM lT QFtOP-QSAL- FOR QFT 0EP7IC MM MM FAld -sing ,MJ1 Irmo. 3; atforc tfalow Wmmt tm ftIlv=omp me prto, t-o any sc2"v a jr o SfTE L_QGaT4N i JOB K �tc S� "t TC1N1V P // -01-1-1 TMI # OW NER'S NAME At MAtLiNLB PAC]POSEb CaN7RAGTd R11N87'AL- L..Ef•7 �rsgs �v «� a PHd7VE # �y�`S��"' �J"!s AGt7FtESS �7 -•c -.-ems— 4 /v- °lot =��9'7 ..`•�y ' �7 ��_ _. _. __ F[EC#iSl'FisiTtOP[ 1L'CEN SE # ,/�G -.�3/- �eept�ora fYar etagsf�c O faiwre fo "--rT:HCa a aaGO -aka iR ?louse L�l tines limitts o/ ay�cvn rqr rspyir a olltier (�g7�ptaM beio� s /ins Cafe: Tian®: f lyl: excel:00pGc 4. PUTNAM COUNTY DEPARTMENT OF HEALTH V/ DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type r' 07it'# Well Location: Street Address: Town/Village Tax Grid JoL ZAJ4L SAlox &C D k PA47011, 5640 N V Ma_p_33 47 Block / Lot(s) g d Well Owner: Name: Address: n Al o j q0 51V' ,Vvlc t (ey 'o-L' U" CAA*1Zt. Ay"/ Of7 y. 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 gal. Reason for eplace 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? .... .............................................................. Yes No Name of subdivision Lot No. a Water Well Contractor: Address: 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 provi ed se p ee Ian. Date: z 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 well driller certified by Putnam County. Date of Issue Permit Issuing Official: Date of Expiration Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 S � - .... _ �.n .. ... __ .. _ ..., .. _. .. -, ,. _. .. 4_� ".. .. � -L r�• �, DEPARTMENT .OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 March 25, 1998 Neil Portney 40 Stoneleigh Avenue Carmel NY 10512 Re: Proposed SSTS: Well Portney, 106 Lake Shore Drive (T) Patterson TM� 25.56 -1 -80 z BRUCE R. FOLEY Public . Health Director Dear Mr. Portney: 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. A location map with contiguous properties shown along with the property owners name and tax map number must be provided. 2. A map showing all sources of contamination within 200 feet of the proposed well must be submitted. This map must be sent with the neighbor notification. 3. Distances from the property lines'to the well are to be noted. Upon receipt of a submission, revised to reflect the above, this application will be considered further. Very truly yours, .tom ,,� ✓ ��� `�124a Robert Morris, PE Public Health, Engineer RM-tn DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 PROCEDURE FOR NEV WELL PEFZNIT APPLICATIONS :_.BRUCE. R.— FOLEY, R.S. -- ---:, Acting Public Health Director 1. Well permit application is to be submitted along with fee, if required. 2. Locations of all sources of possible contamination within 200 feet of the proposed well. location are to be shown on a plan or tax map. 3. Contiguous neighbor notification is required. 4. Feasibility of well location is to be confirmed by a representative of this Department. 5. If the proposed well is within 15 feet of the property line the approved well location is to be staked by a licensed surveyor. If the proposed well location is within 100 feet of any source of contamination the well location is to be staked by a Licensed Engineer, Registered Architect or. Land Surveyor prior to drilling. 6. As built and well log to be submitted no later than 30 days after completion, by permittee. ERF /RM /ip August 1995 b �a DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278 - 6130 Fax (914) 278-7921 NEIGHBOR NOTIFICATION APPLICATIONS WELL PERMIT BRUCE R. FOLEY .. Public Health Director Beginning August 12, 1995 applications to the Department of Health for Well Permits will not be reviewed until such time as the Director of Environmental Health Services of the Department of Health is provided with proof that notification of the application for construction was made to all property owners contiguous to the property in question. A location map (a tax map ,vould suffice) with contiguous properties shown along with the property owners name and Tar Map 9 must also be provided to the Department. 'Notification shall mean receipt by each contiguous property owner of a copy of the attached notification form along with a copy of the latest site plan. Proof pf receipt of notice by contiguous property o«N can include either of the following: I . Copies of registered mail receipts. (Return receipts) 2. Copies of the notification form signed by the contiguous property owners. Failure to provide the Department with adequate documentation of the performance of the notice will result in our delaying action on the.application until proper notice is executed. Transmittal of this notification should be sent to the contiguous property owners by the applicant or well driller. A format of this notification form is attached for your use. BRF/RVVjp AWP a 'a BRUCE R. FOLEY, R.S. Acting Public Health Director DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 FORMAT NEIGHBOR NOTIFICATION CONSTRUCTION PER11T Dear DATE RE: Department of Health Review of Proposed Sewage Disposal System and or Well NX ME: ADDRESS: TOWN-: TAX -\L-�P: Please be advised that an application for a Construction Permit relative to the construction of a sewage system and'or well proposed for the above captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have anv questions, concerns or information which may bear on the Health Department's review of this application, you may call tilr. ylorris of the Health Department at 278 -6130. RECEIVED BY: ADDRESS: TAX -kLkP: BRF/jp syswell N'ery truly yours, BY TITLE: APPENDIX E FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER Date V// / �, � RE: Department of Health Review of Proposed SewageTreatment System for Property Name: ,< ;`l o Address: i3 Town: Tax Map #: Dear Please be advised that an application for a Construction Permit relative to the construction of a sewage system and/or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call the Health Department at 278-6,130. Very truly yours, Received By: O(k, l Al2�' -'`% Address: Tax Map #: 2,,r— By: �J Title: August 1997 25 APPENDIX E FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER Date RE: Department of Health Review of Proposed SewageTreatment System for Property Name: Address: �C- L 0 1 Town: Tax Map #: Dear Please be advised that an application for a Construction Permit relative to the construction of a sewage system and/or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call the Health Department at 278 -6130. Very truly yours, VJ Title: Received By: f t) Address: Tax Map #: August 1997 25 APPENDIX E FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER Date z/ RE: Department of Health Review of Proposed SewageTreatment System for Property 'Name: Rum /9 .A) 0 Address: e Btu,a R iC3.q 1� Town:, -�� Tax Map #: Dear Please be advised that an application for a Construction Permit relative to the construction of a sewage .system and/or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call the Health Department at 278 -6130. Very truly yours, By: °6,&k k �.J . '�, �'•e rWi ��Lw� Title: Received By: Address: Tax Map #: ti )'V. August 1997 25 APPENDIX E FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER Date 41V RE: Department of Health Review of Proposed SewageTreatment System for Property Name: Address: Town: Tax Map #: Dear Please be advised that an application for a Construction Permit relative to the construction of a sewage system and/or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call the Health Department at 278 - 61`30. Received By: Address: Tax Map #: Very truly yours, By: Title.�r- August 1997 25 APPENDIX E FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER Date 1j i y s RE: Department of Health Review of Proposed SewageTreatment System for Property Name: Z C; C) A to Address: Town: Tax Map #: Dear Please be advised that an application for a Construction Permit relative to the construction of a sewage system and/or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call the Health Department at 278 -6130. Very truly yours, "� Title: Received By: PO ►2��.� Address: Tax Map August 1997 25 APPENDIX E FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER Date RE: Department of Health Review of Proposed SewageTreatment System for Property Name: /,3-Al A to D l.� C. CS T Address: -a r�U:c• �Z>> Town: on q Tax Map #: Dear Please be advised that an application for a Construction Permit relative to the construction of a sewage system and/or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call the Health Department at 278 -6130. Very truly yours, By. 1 PO Title: Received By: I Address: Tax Map #: �fk", -)— -• % August 1997 W APPENDIX E FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER Date RE: Department of Health Review of Proposed SewageTreatment System for Property Name: iS 0-1 le $1-177 0 Address: �' Y L'r-. �'�• °"` Town: D Tax Map #: Dear Please be advised that an.application for a Construction Permit relative to the construction of a sewage system and/or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call the Health Department at 278 -6130. Received By: PO IAN"% Address: Tax Map T 1- - -- ` - - -I -- -- - - - - - - August 1997 25 APPENDIX E FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER Date RE: Department of Health Review of Proposed SewageTreatment System for Property Name: Address: 'L 4 Town: Tax Map #: Dear Please be advised that an application for a Construction Permit relative to the construction of a sewage system and/or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call the Health Department at 278 -6130. Very truly yours, 0 Title: OW *) ,g- i1. Received By: , a %, S--'6 k-r, -� } Address: 1� z) 16 Tax Map #: c)t - �� -- 2— — August 1997 25 APPENDIX E FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER Date RE: Department of Health Review of Proposed SewageTreatment System for Property Name: Address: Town: 'Tax Map #:' Dear Please be advised that an application for a Construction Permit relative to the construction of a sewage system and/or well proposed for the captioned property has been made to the Putnam CounVy Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call the Health Department at 278 -6130. Very truly yours, By: Title: Received By: Address: Tax Map #: j August 1997 5649 1 11 5651 5650 II 565 2 1 5654 1 5653 I 83. — rod found 'S0 2. y 9'57 2.1 x ' rood • E .I.co!! 'once ' fe�,.e • O.o m.etal Fosts:.i..' 'r a . t. U' �' . • 56671 lhs'u 5669 > I 646, deck A,,a4410 267 �s4 TAX !U 1U U.S w 0.2357IACre / I ty O I OT 1 1. ^ 1 7.I' E store Q I Az ! t\ � o��' a i' • H ' 1 f 33 i s •p v16 1.5•E 7 \ �C 12 e TUR Y R AYE P E! ! 1 .LOT 1I p W 1 `e N Y ' plk T 'i �, t O o 1 n 4 O R t v F r .LA c, 'U',- r L--03.09' I?�525.00 n ?T WE: T ::r Rri�r: GF LOT 5652 A,!` . F " -. T Sc" D. 5h•Ov,11 :4EREO.v ASE AS AER TOW '. ?/: iAX AAAr S /JL N 7 :;UR Vr YEZ'. . DRr� jj �� LL -1 ' L . p'.4 . G k CA%3ss )3 m 2 -7 G /3U X /G� SURVEY OF PROPERTY PREPAf: _for A-T _' _YORK MORTGA Gam' ,S`-E DV Being lots 5644 Mru 5646, 5667 thru 5669 on a snap entilUd Vc.p of Pidnam LakF •• filed in fU Putnam County Clerk s Offer no. 149F on Afar. 20. 1931. Si t z�atE in the i TT r7 r I f'y to t r { { { 5652 5651 5650 { 5654 { 5653 rod found 60:00' 0.2' N 0.6' E N89'S7' . . ,,.,.►� metal posts 5.2 w hl u 5669 0 deck Lots 06ts 5645 & 5646 o to & P/ S ` . of Area 6.939 4 Acres R. Iv a m 0.3' W 14) 0,1593 13.4' —� t� N89 °57'50 "W 17.71' °+ c D ADOPTED BY THE �. OF PROFESSIONAL o c m s' wood D.RI v 1` n i 0 shed m s DIRT 13.0• + s. o' o. 0. 2' w A '`� e wee p Off qV`o wall over �� fp h 00 1 11 ose / r y O • x 1.5E Q ONE � STORY a, o FR AME 1 1WELLfNG NZ n of NOTES: I. HORIZONTAL POSITIONING BASED ON MONUMENTS FOUND AT NORTHWEST CORNER OF LOT 5662 AND THE SOUTHWEST CORNER OF LOT 5631. FRA ,d B No SURVEYORS / OILS CE 77FI CA TIO/ tl COPYRIGHT © 1997 DONALD J. DONNELLY,, ALL RIGHTS RESERVED o UNAUTHORIZED ALTERATION OR ADDIRON TO THIS DIR T a 0. EXISTING CODE OF,PRACTICE FOR LAND SURVEYS c D ADOPTED BY THE �. OF PROFESSIONAL o c LAND SURVEY . E D.RI v 1` n FOR WHOM 7H1 19 RED AND ON H,•S BEHALF TO !77Y Cin AND COPIES THEREOF ONLY IF SAID MAP OR COPIES a ENNL�ING INSTITUTION LISTED HE r s DIRT ° E L- 33.09' v n,0 RI VE t - " • N 01 A '`� E )?--525.00' S83'51' 0'`E' 175.6 YORKTOWN HEIGHTS, NY 10598 ` t , 1 LA C®lD,4 Covement `\ d/��V �\ NOTES: I. HORIZONTAL POSITIONING BASED ON MONUMENTS FOUND AT NORTHWEST CORNER OF LOT 5662 AND THE SOUTHWEST CORNER OF LOT 5631. FRA ,d B No SURVEYORS / OILS CE 77FI CA TIO/ tl COPYRIGHT © 1997 DONALD J. DONNELLY,, ALL RIGHTS RESERVED CERTIFICATIONS INDICATED HEREON SIGNIFY THIS UNAUTHORIZED ALTERATION OR ADDIRON TO THIS SURVEY WAS PREPARED IN ACCORDANCE M7H 7H£ SURVEY 15 A OOLAT70N OF N.Y.S. EDUC. LAW EXISTING CODE OF,PRACTICE FOR LAND SURVEYS SECTION NO. 7209. ADOPTED BY THE �. OF PROFESSIONAL LAND SURVEY UNDERGROUND STRUCTURES, IF ANY, NOT SHOWN, CER71F7CA77 THE PERSON ALL CERTIFICATIONS ARE VALID FOR THIS MAP FOR WHOM 7H1 19 RED AND ON H,•S BEHALF TO !77Y Cin AND COPIES THEREOF ONLY IF SAID MAP OR COPIES a ENNL�ING INSTITUTION LISTED HE r BEAR 7HE RED INKED SEAL OF THE SURVFYOR WHOSE SIGNATURE APPEARS HEREON. CER77FICA77 ABLE 70 _.. .. _ ...._ .. ADDITIONAL l EoUENT OWNERS. DONALD J. DONNELL Y,, L.S. 7929 COMMERCE STREET YORKTOWN HEIGHTS, NY 10598 DONALD J DONNEL Y, WS LIC. NO. 740 PHONE: (914) 962 -2215 FAX: (914) 962 -2209 4493- 48- 3- 12- GALIZIA i Cert i.f. 1. Cdn PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION_TO CONS.TR_ UCT.A WATER WELL. . please print or type PCHD Permit # Well Location: Street Address: TownNillage Tax Grid # 06 all (7)- /O Map Block Lot(s) Well Owner: Name: Address: Use of Well: Residential Public Supply Air /Cond/Heat Punif 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 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason /aG� for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ............................. .......!....... ............................... Yes No ��.�.,, Is well located in a realty subdivision? ......................... ........... ...................... Yes =o Name of subdivision Lot No. 4` Water Well Contractor: T Address: Is Public Water Supply available to site ................................... ............................... Yes No Name of Public Water. Supply: /� �. Distance to property from nearest water main: Town/Village rov Proposed well location & sources of contamination to be i P P o e eet/ lan. " P ✓ . Date: .. ._. _.. .Applicant.Signaturel: .. ._. ./ 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 well driller certified by Putnam County. Date of Issue /� i���. �% %� Permit Issuing Offici Date of Expiration ey�11� Title: In Permit is Non- Transferrab White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 ., �V DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 March 25, 1998 Neil Portney 40 Stoneleigh Avenue Carmel NY 10512 Re: Proposed SSTS: Well Portney, 106 Lake Shore Drive (T) Patterson TM# 25.56 -1 -80 Dear Mr. Portney: BRUCE R. FOLEY Public Health Director 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. A location map with contiguous properties shown along with the property owners name and tax map number must be provided. 2. A map showing all sources of contamination within 200 feet of the proposed well must be submitted. This map must be sent with the neighbor notification. 3. Distances from the property lines to the well are to be noted. Upon receipt of a submission, revised to reflect the above, this application will be considered further. Very truly yours, Robert Morris, PE Public Health Engineer RM:tn � a - - - BRUCE •R.FOLEY, R.S. Acting Public Health Director DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 PROCEDURE FCtR NEW WELL PERMIT APPLICATIONS 1. Well permit application is to be submitted along with fee, if required. 2. Locations of all sources of possible contamination within 200 feet of the proposed well location are to be shown on a plan or tax map. 3. Contiguous neighbor notification is required. 4. Feasibility of well location is to be confirmed by a representative of this Department. 5. If the proposed well is within 15 feet of the property line the approved well location is to be staked by a licensed surveyor. If the proposed well location is' within 100 feet of any source of contamination the well location is to be staked by a Licensed Engineer, Registered Architect or Land. Surveyor prior to drilling. 6. As built and well log to be .submitted no later than 30 -days after. completion, _.__.......... by permi.ttee... _. _. BRF /RM /]p August 1995 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 NEIGHBOR NOTIFICATION APPLICATIONS WELL PERINJIT BRUCE R. FOLEY Public Health Director Beginning August 12, 1995 applications to the Department of Health for Well Permits will not be reviewed until such time as the Director of Environmental Health Services of the Department of Health is provided with proof that notification of the application for construction was made to all property owners contiguous to the property in question. A location map (a tax map would suffice) with contiguous properties shown along with the property owners name and Tax Map 9 must also be provided to the Department. Notification shall mean receipt by each contiguous property owner of a copy of the attached notification form along with a copy of the latest site plan. Proof of receipt.pf notice, by contiguous. property owners can include either of the following: 1. Copies of registered mail receipts. (Return receipts) 2. Copies of the notification form signed by the contiguous property owners. Failure to provide the Department with adequate documentation of the performance of the notice will result in our delaying action on the application until proper notice is executed. Transmittal of this notification should be sent to the contiguous property owners by the applicant or well driller. A format of this notification form is attached for your use. BRF/RVUJP AWP 1 �i BRUCE R. FOLEY, R.S. Acting Public Health Director DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 FORMAT NEIGHBOR NOTIFICATION CONSTRUCTION PER -20T DATE RE: Department of Health Re�dew of Proposed S%-wage Disposal System and'or Well \.�NIE: ADDRESS: TMV-\ : TAN NLAP: Dear Please be advised that an application for a Construction Permit relative to the construction of a sewage system and!or well proposed for the above captioned property has been made to the Putnam County Department of Health. Attached please find a cope of the latest site plan. If you have any questions, concerns or information cN-hich may bear on the Health Department's rex -iew• of this application.'you may call %1r. 'Morris of the Health Department at 278 -6130. Vern truly yours; RECEIVED BY: ADDRESS: TAX MAP: BRF/jp syswell BY TITLE: , IL ` it 1 V i P i cG. 5653 I 56$1 13' .65�0 < 56 f, qy\ . j 13' E _ 6 fund y 0 a ' y 5 9'57'50E 1" x 2.1' rye C) 0. E �rcoc' fence fence ;� ) n..tat Putts 2.3' I h, 5669 dock I646 � 5 667 Lots 1? 627SSQ6 . 3 W 0.2957 A 1eS o� o \ C-/ LOT j1� --�C. 1.1' s ona I TAX ` \y 4'v IT) f_ l ` 1 f 0 I \¢GN art' .g'E 7 SLOT 12 I 5 TOR Y w fLLINO \ C f O V j 0 k, V£ `may ,d,y� \� e L I — 0 E L= 33.09" B-525.00' "8• 1'5 Ly%e0Nn f .. _ . \. .mot PI_/r..'.fT:;Li- , "b- L•N:NG PAfEG ON A ;d_RP -* WES T r, r, GF.LGT 5662 AND OU;?,:,F_. ,-T -CRNER OF LOT 5E.31. 'T ! %fE: SHO1+'1f HEREON ARE A_ PER TGWT-' r7ck ' ✓h' FAY A4 AFS AND NOT EURV -YEL'. ,1-- � G I ' Fr Y J�`' ••�� - - - a7' !J �G.r/ v"�+ L 6Ca.r G� ��a/o 63 - -- SURVEY OF PROPERTY PRFPAI fib r jE _ " YORK 14IORTGA GL'_,S'EE P j Being lots 5644 thru 5646• 5667 thru 5669 on a atop enlilled f _,Yap of pulnanl. Lakc - filed in the Putnam Co2Lnty Clerk S Offir" no, f4.9F on Mar. 20, 1931. Situate i71 the