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HomeMy WebLinkAbout1344DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.78 -1 -45 BOX 13 01344 y J ' L 71 ML ' '` P! ban 01344 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL y� please print or type PCHD Permit # V Well Location: Street Address:" Town%Village Tax Grid # 1- S- t u m wA. Lf -R -1d. Map Block Lot(s) Well Owner: Name: Jat.-1.t 'ba w t a is Address: P-o - 6 1 r1 kLv "ale Y l (7`f'Z/ 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 S- gpm # People Served _ Est. of Daily Usage :fin gal. Reason for 7KReplace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well oGtr Detailed Reason -r, w eW W Ail W L'I-h i" SI d v 1 of for Drilling © w - act cK a W e Well Type —� Drilled Driven Gravel Other Is well site subject to flooding? ..............................................:.. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No K Name of subdivision L Lot No. tai Water Well Contractor: c9 of tQH 41 ,Qk Ca Address: - [0 25' kf 5--- "c4 Is Public Water Supply available to site? .................................. ............................... Yes No k 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: 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. An revision or alteration of the approved plan requires a new permit. Well to be constructed by a water w 1 'ller certified by Putnam County. Date of Issue 2,J iz_1 o 2 Permit Issuing Offici !✓ Date of Expiration Z o Title: Permit is Non - Transfer able White copy- HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WP -97 -1T m X A�8P11tl9 COON N II ���� �fYE6S11S��Ytl PCHD Permit # 02- O Z Telephone # Street Address ('-? U V►'l vti� ' Tom Gi "4 Name � , Date fh&e J 1. Application To Construct A Water Well WP -97 subnntteV V/ Reason for Drilling Yes No NA Comments 2. Certified Check or Money Order of $100.00 3. Site Plan Existing Well Paco o� _sed. Well Septic S House 4. •... ........ .. Site Ptan vii u•- cal ti 1�taLWtaJ _ 200 FOOL ..._ ... ... _.. _. ... ..._ ., ._ '. ... ...... •....... _ _ _ _.._. ._.... .. ... ...- _. _.. _ _ _ 5. Neighbor Notification Telgphone Log a A PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Town/Village: Tax Grid # Map lock 1 Lots) 05 Well Owner: Name: Address: Use of Well: Y- primary 2- secondary Residential Public Supply Air cond/he pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _Z Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length O ft. Length below grade 4_JZft. Diameter (5in. Weight per foot lb /ft. Materials: X, Steel _ Plastic Other Joints: _ Welded i< Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield ,/ J gpm Depth Data Measure from land surface - static (specify ft)., - A// During yield test(ft) IL a= Depth of completed well in feet 305 Well Log If more detailed information descriptions or sieveana!yseC.._ are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface Y 3de &NA05S /z __. _.. :... .. __. .. __.. .... __ _. .. .. _.. ._.. ..._ .. If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Iorrmation Pump Type Capacity Depth Model Voltage HP Tank Type Volume vy 4,V1 Date Well Completed -/ -©:72 Putnam County Certification No. Oa3 Date of Report x=0.3 Well Driller ignature) NOTE: Exact location of well with distances to at least two permanent landmarks to be proviqepn a separatorsheettplan. Af- �dl� jo 4; Well Driller's Name Address: G Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PIT NAMCOUN YDEPARTNI N WHEAT U DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location' Street Address- Town/Village: Tak Grid Map Los) 5 54BIock t( Well Owner: Name: Address: Use of Well primary 2 -sec- ndary' .0 A ond/he4f i)iim'p:' Residential Public ,84 Supply ir,c. .,. Business Farm Testhrionitoring Other(s P ecify). Industria Institutional Standby Drilling Equipment , Rotary Rbt' Cable percussion u, Compressed air percussion Other (specify) Well Type -Screened . Open end casing Open hole in bedrock Other Casing'Detaik . Total length ft. Length below grade /1 Diameter h in: Welightpq.166t -Iblft. Materials: Steel Plastic Other Joints: t Welded X Threaded Other Seal:. pment, grout Bentonite Other Drive'shoe�' )r "Yes.,. X'- es. No Screen Details Diameter (in) Slot Size, Len ft ptfi to Scree De n (ft) Develope A9 First Yes No Hours Second Well Yield Test _Bailed 'Puftped Compressed Air Hours -7 i eld 5 gom. Depth D Measure re from land surface static (specify ft) During'yield test(ft) Depth of completed well in feet 05 Well If more detailed. information descriptions or sieve.analyse§.,-:,'.'- are available,- please attach. De From in Surface' Water Bearing Well Dia etee(in) Formation Description ft. ft. Land Surface Ilhl'm /Z A F 0 If yield was tested at different depths. during drilling, list: Feet 'Gall6fis Per Minute PU*Storage Tank Infb Pump Type Capacity Depth Model Voltage HP Tank Type Volume j a "Illit Pate Well Completed Putnam County Certification Noe Date of Report Well Dr. tr. signhtur' Nui'E: txact location ot-wen with aistances to at least two permanent lanaMarKS to be,proviqecLon a' separate sneet/pian. Well Driller's Name r Address: Signature: A11111-7 Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 'Q1 6 ..D 'r PUTNAM COUNTY DEPARTMENT OF .HEALTH DIVISION OF ENVIRONMENTAL, HEALTH SERVICES ,...,`.... APPLICATION TO,CONSTRUCf' A WATER WELL PCHD'Permit # please orint or rvoe Well. I,ocatlon: Street. Address: Town/Village Tax Grid #.. 5, t7a d ; l � Wt Wf t 1 Lr (: °,, VS 0, 0 _ 'map . Block Lot(s) Nell Owner. Name: Address Z7serof Well `Residential Public Supply`: Air /Cond/Heat Pump Irrigation 1- primacy Business Farm '.` Test/1Vlonitoring Other (specify) 2- sec6hdaay Industrial institutional Standby Amount of Use Yield Sought �5— gpm . # People Served 7- Est. of Daily Usage 3 gal. Reason for ; Replace Existing' Supply . Test/Observation Additional Supply. Drilling New Supply, (new dwelling) Deepen Existing Well _ Er L De`ta>�led Reas ®n ., t' a G 1 u� 'i,1 � for i)r lling Well. Type Drilled Driven Gravel Other .. ........ ....................... Is well.' site subject to flooding? .............. .......................... Yes No �. Is well aocated in a realty subdivision?.. .:......................... ............................... Yes No y Name of subdivision ' L Lot No'. Water .Well Contractor: to vi Address: j 0 5 `f .l* S a Is Pub lic Water Supply available to site? . ., ........ . .... ..............:...::.. :....................... Yes No Name of Public Water Supply:: Town/Village Distance 4o property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan Date:.. ,l `:J2 Apnl�cant..S�gnattire: ._� _ __ ..._...:,............ PERMIT TO CONSTRUCT A WATER WELL ? � is This permit to construct one water well as set forth above, is granted under, provisions of Article:l p of •tfhe'. E Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code andy oy ded ` 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 accordanceA� nth the - y requirements of the Putnam County Health Department. 3) Submit a Well Completion Reportfon :a form -- provided by the Putnam County Health Department. During all.well drilling operations tlo- applicant:and/or f' well driller shall take appropriate, action to assure that any and all water and waste products from suc h. 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 ffomthe date issued unless construction of the well has been completed and inspected by the PCHD and is evocable for cause or may be amended or modified when considered necessary by the Public Health Directors Any revision or alteration. of the approved plan requires a new permit. Well to. be constructed b f a wateryvell friller certified by Putnam . County. Date, of Issue - 1- a Permit Issuing .Offici 4 i.�°` Date of Expiration 2 J I Title: Permit is lion- Transfer able White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 BRUCE R, -. POLE .. Public Health Director DEPARTMENT OF 1 Geneva Road Brewster, New York 10509 T.ORETI A 46bI RI R.N , M. S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Boyd Artesian Well Co. 1054 Route 52 Carmel, NY 10512 January 29, 2002 Re: Proposed Well: Daniel 17 Summit Road (T) Patterson Dear Mr. Boyd: Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: 1. Site plan (or tax map) of property showing locations of proposed well, existing septic system and house. The well. shall be dimensioned from two -fixed- - ._.__._.... __—.__.___.__ _.___..._.._.._..__.._..__...._ 2. The site plan is to also include location of all existing septic systems and wells within 200 feet of the proposed well as well as all possible sources of contamination within 200 feet (i.e.< salt storage, oil tanks, land fills....) If there are any questions please contact the writer at (845)278 -6130 ext. 2235. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, 1�;'t I ";'I �� Dan1e1 Hadden Public Health Technician cc: RM PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL P_keso orintor_rym . _ _ PCHD Permit # Well Location: _ Street Address: Town/Village Tax Grid # �5t lin Su M W4+ Ti_>d- ` _1_1L a" Map Block Well Owner: Use of Well: 1- primary Amount of Use Reason for Detailed Reason for Drilling Well Type I — q-s Name: riuure56; Residential Public Supply Air /Cond/Heat Pump Irrigation Business Farm Test/Monitoring Other (specify) Industrial Institutional Standby Yield Sought gpm # People Served _7 Est. of Daily Usage al Replace Existing Supply. Test/Observation Additional Supply New Supply (new dwelling) ' Deepen Existing Well 1 Drilled ' Driven Gravel Other subject to flooding? Yes No K Is well site subj ...................... ............................... No K Is well located in a realty subdivision? ....................... `............ ............................... Yes Name of subdivision 2 Lot No. Address:. • .- Water Well Contractor: 8 k 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 provided on separate sheet/plan. Applicant Signature: rn Date: PP PERNUT 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 ed on this roperty tand in such water anneras not products degradfrom r otherwise well drilling operations be P 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 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Boyd Artesian Well Co. 1054 Route 52 Carmel, NY 10512 February 5, 2002 Re: Proposed Well: Daniel 17 Summit Road (T) Patterson. Dear Mr. Boyd: The site plan that submitted for the above regarded project has been received by this Department on February 4, 2002. Review of plans and other supporting documents submitted at this time has been completed. Comments are offered as follows: t,.. Neighbor- notifica ion - documentation = Neighbor notification form signed -by - -- property owner or returned certified return receipt requested from the U.S. Postal Service. This is required for replacing an existing supply over 5 feet from the existing well. If there are any questions please contact the writer at (845)278 -6130 ext. 2235. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, Daniel Hadden Public Health Technician cc: RM BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Boyd Artesian Well Co. 1054 Route 52 Carmel, NY 10512 January 29, 2002 Re: Proposed Well: Daniel 17 Summit Road (T) Patterson Dear Mr. Boyd: Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: 1. Site plan (or tax map) of property showing locations of proposed well, - _ .existing- septic'system and-houEd. -The swell shall be dimensioned. firem two--_ fixed points. 2. The site plan is to also include location of all existing septic systems and wells within 200 feet of the proposed well as well as all possible sources of contamination within 200 feet r.e.< salt storage, oil tanks, land fills....) If there are any questions please contact the writer at (845)278 -6130 ext. 2235. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, Daniel dden Public Health Technician cc: RM y xii 7 i ul am 11% eeomllr M e 0,00 10E101 //'.....25.79 am 11% .25.7T __ eRWmeR11[ eteE ot,M10 LN C m -- p61i.Ifminua , =m 36.:22.'36.23 _ _ .rrJ s rplm wwm 437 PRELIMINARY MAP 236 SCALE r • so' TOWN OF PATTERSON PUTNAM COW". 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