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HomeMy WebLinkAbout1346DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.78 -1 -47 BOX 13 01346 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES V �v 1 54.. APPLICATION TO CONSTRUCT A WATER WELL piease print or type PCHD Well Location: Street Address: Town/Village Tax Grid # f Sliim fArr P ' e Map , 7 g Block Lot(s) Well Owner: Name: 4INh/� M 1 Address: e-kX44)b - ROMANt I a fik -A Aug Ypy&gP9 IvY 076 Use of Well: -4/*" 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 — 9 Est. of Daily Usage gal. Reason for. Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason C v l ev .0 IF 'u for Drilling Well Type Dri lled 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. Water Well Contractor: B6 Yt ' 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 provided on separate sheet/plan. Date: Applicant Signature:. CD PERMIT TO CONSTRUCT A WATER WELL 1,his permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam ty Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that wi (30) days of the completion of water well construction, the applicant or their designated representatha shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirpmetf the Putnam County Health Department. 3) Submit a Well Completion Report on a form prov y1� ided 1 e Putnam County Health Department. During all well drilling operations, the applicant and/or well;'drll s`1t' all take appropriate action to assure that any and all water and waste products from such well (Wi perations be contained on this property and in such a manner as not to degrade or otherwise coritamin surface or groundwater. c� 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. .3� — ©Z Permit Iss ' Offic'al: Date of Issue g Date of Expiration -O Title: APW Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �v� S�A APPLICATION TO CONSTRUCT A WATER WELL please print or type - _ ' PCHD' Well Location: Street Address: TownNillage Tax Grid # f StlM f-,j -( PoTafeR Map*"�179 Block Lot(s) Well Owner: Name: 1,I~ MA1 Address: e. LAKA t o � R®Mpwi 1 8:3 AEKA AVE Yo,0140f /07e Use of Well: --ice 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 j_:* Est. of Daily Usage gal. Reason for _ e//Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason �. v tj tW A1,X0 M 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. Water Well Contractor: 13 6 Address: Is Public Water Supply available to site? .................................. ............................... Yes No t/ 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: C' 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 (3 0) 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 Date of Expiration Permit is Non- Transferrable Permit Issuing Official: Title: White copy - HD file; Yellow copy - Building Inspector; Pink copy -.Owner; Orange copy - Well driller Form WP -97 d c y S d d 4 y h i 6 3 03 N� i APPENM E 0 aru ra 0411ma, s Date RE: Department of Health Review of Proposed Sewage Treatment System for Property Name: Address: I S 4WAI D b . Town: �TEQS'o�u Tax Map #: j- 5 , T P -- 1 —' 7 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-fard -a copy bf 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 (914) 278 -6130. Very truly yours, By: �'�yt�v� � Title: own, EI2 Received B� `t Address: S u wt yl t i ! Tax Map #: 7 August, 1999 AppndxE APPENM E M __LjW3L all Date RE: Department of Health Review of Proposed Sewage Treatment System for Property Name: Address: 13 �'' �► i1P1� l�- Town: PA- r—m-2SOA) 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 _ epartment 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 (914) 278 -6130. 1 L.1., (�y -yl•� µ l� / YYt 9�1 1 G' AD Very truly yours, By: ��y►�-eM. Title: OWNER Received By: ^:.i : ;'�d.:rw� Address: iiI .SY/Y AO 17 Tax Map #: Z 5 r 7k-- / -! l August, 1999 AppndxE , . 25 APPENM E •• • NMI • • Date 1 Z RE: Department of Health Review of Proposed Sewage Treatment System for Property Name: 4iAQNII e tA14Pro RoMkv) Address: "'13 S4IIN t-1- ' Town: Pprr (1�5R..SOAJ Tax Map #: � , 7 (f J `-0 Dear . Please be advised .that an application for 'a Construction Permit relative to the construction of a - sewage system and /or .we.U..Ptoposed.fo..r t`.e -car. ioned.pronerty has been made to the.P.utnam. 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 (914) 278 -6130. Very truly yours, -P v ^ fJ ,��Nla By: Title: Received By: Address: 3 C - Tax Map #: August, 1999 AnnndxE Dear... �,vvu 'ts, A 11 25 APPENUX E �a • Date RE: Department of Health Review of Proposed Sewage Treatment System for Property Name: abvr�A MAIZE! CkA4a11O Address: 13 .5,, /" t f Town: IAA -r*l'"F, ,". ) Tax Map #: 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 (914) 273 -6130. -*Received By: 13�' Address: 15 (A Mh t Tax Map August, 1999 AppndxE Very truly yours, By: Title: 6 w ti f '2 r Dear... 25 APPENUX E Date RE: Department of Health Review of Proposed Sewage Treatment System for Property Name: RoMf*v t Address: 1S S'uh Town: Soul Tax Map 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 - - - .L�epa•�*nlent of ;iealth: -Attached- please firid -a -copy of thd' 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 (914) 273 -6130. Very truly yours, By: '' _ ��oy►��,,� , (� p Title: 0 LL, A F Received By `t -�✓ G,�.a�l�i I IV Address: /�`1 sw- r Tax Map 9: r 7,` r/— �–�— August, 1999 AppndxE 25 vy . APPENM E FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER Date RE: Department of Health Review of Proposed Sewage Treatment System for Property Name: Address: "t 3 Sk Town: Q�'C�Rsoi1/ Tax Map 4- Dear Please be advised that ari application for a Construction Permit relative to the construction of a sewage system-aau/oF -vr„u r•oposed- for•tV cap *acned.pr- oper -sy -has been made, .to..the, ..utna_m._ .ounty . - -. - _..... _ -_. _....._.. 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 (914) 278 -6130. Very truly yours, pAAvyi�L iz'-rpy— L By: �-Isooi Title: 0 W N E, Received By: Address: a' Tax Map 9: August, 1999 ApondxE :_ _ ........... . .... ...... Dear. . 25 APPENUX E Date RE: Department of Health Review of Proposed Sewage Treatment System for Property Name: L W tA, MX10 _ <t ALA o R. M,�v i Address: 13 EtiAjhj ( Alh Town: PAT-r1*SDry Tax Map 9: 9 -2 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 Count ..� Department of Health: - Attached-please firri a-copy -of the latest site plan..w _.._ _ ..... _.. Y _ .....:... _ _._ ._ ........_..._ . _ . 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 (914) 273 -6130. Received By: Address:, Tax Map #: 2 v 7— 3 6 August, 1999 AppndxE Very truly yours, Title: OU1A)6P i Dear. 25 APPENM E FORMAT CONSTRUC'T'ION PERMIT NEIGHBOR NOTIFICATION LETTER Date RE: Department of Health Review of Proposed Sewage Treatment System for Property v :a�� A�,Mtlt4lt Pit i ame Address: y� �-- Town: Tax Map #: —Z— ` •7 Please be advised that an application for a Construction Permit relative to the construction of a o e y.. proposed for- - *:�ie cap *coned- pr- oP�:.; has to�thP - .utraar� _ -ounc . _..._ _....�.,.. _.. _... _.:...__ ...- ... - - -- 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 (914) 278 -6130. Received By: Tax Map # v �� . -5 J 7 August, 1999 AoondxE Very truly yours, By: 1l0 )A) ZZ�iI' Title: (?) W JLO APPENM E 14011M _E , Date RE: Department of Health Review of Proposed Sewage Treatment System for Property n Name: C OAM WXLX -: I CCA�� 10 Address: 13 F RD Town: PA''1ERS '1N Tax Map #: s,5 -2F— (_' q 7 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 I �calth: 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 (914) 278 -6130. Received By: Very truly yours, By: • Title: Address: Z-� Tax Map #: -3 %- August, 1999 AppndxE APPENUX E o • *..�' Date RE: Department of Health Review of Proposed Sewage Treatment System for Property Name: C<A4D1a �o,fl' "i Address: 13 S ct 1VW- Ra Town: MI �90A) Tax Map #: Z 5, 7 ,P-1— y 7 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 _ epartment of Iealth. Atfaciie­d piease ffH 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 (914) 278 -6130. A101Rs 1 v 1 l Received B- Address: T 17— Tax Map #: 2—�j 7 August, 1999 AppndxE Very truly yours, By: Title: _ o w/ )EQ BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORE17A 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 Mr. Henry Boyd Route 52 Carmel, NY 10512 Re: Proposed Well: Mazzi 13 Summit Road (T) Patterson, TM# 25.78-1-47 Dear Mr. Boyd: December 19, 2001 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: Enclosed, please find the current code requirements for a well permit. Items 1., 2 and 3 have not been ........ ..... Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve ly Yours Robert Morris, P.E. Senior Public Health Engineer RM:ta enc. BRUCE R. FOLEY Public Health Director a (QORETrA MOLINARI R.N., M.S.N. Zj O�� Associate Public Health Director Director of Patient Services DEPARTNENT OF EEALTH 1 Geneva Road Brewster, New York '10509 Environmental Health (914)278-6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 60I4 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 To: All Well Drillers, A ensed Engineers and Registered Architects From: Bruce R. Foley Subject: Neighbor Notification Date: August 18, 1999 Please find attached this Department revised procedures relating to Well Permit Applications. _ $houldyouu_haye. any - questions oii thes.e..proced.t.ires, please- contact -this. office— Thank you, BRF:tn BRUCE R. FOLEY 'ublic 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 (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fa: (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 NEIGHBOR NOTIFICATION 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 within 200 feet of the proposed well location. A location map (a tax map would suffice) with all properties shown within 200 feet of the proposed well location must also be provided to the Department. An example location map is attached. Notification shall mean receipt by each property owner of a copy of the attached notification form along with a copy of the latest site plan. _........._ _.. roo .o_ rec., .pt of =ice ; } property owners car, InciiidC either of the foliowlnu. 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 riotification should be sent to the all property owners within 200 feet of the proposed well location, by the applicant or well driller. A format of this notification form is attached for your use. BRF/%M/tn August, 1999 is APPENDIX E FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER Date RE: Department of Health Review of Proposed Sewage Treatment System for Property Name: Address: Town: 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 Dep,ULnient of Health.`-Ati.ached 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 (914) 278 -6130. Very truly yours, By: Title: Received. By: Address: Tax Map . #: August, 1999 . AppndxE BRUCE;... R.: FOLEY . Public Health Director _, -ORET TA -MOLiNARI R.N., M.S.N: Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 218 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 NVIC (914) 278 - 6678 Fax (914) 278 - 6085 PROCEDURE FOR NEW WELL PERNMIIT APPLICATIONS .1: Well permit application is to be submitted along with fee, 5100.00 certified check or money order, for all permits other than redrills. Redrills require only permit applications. . 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. Neighbor notification is required for all property owners within 200 feet of the proposed well location.. 4. Feasibility of well location is to be confirmed by a representative of this Department - - L`the proposed well is within 5-fce� off-the property-- line -the approved-weli,loc -ation t-to 15e-- - 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 driilling. 6. As -built and well log to be submitted no later than 30 days after completion, by permittee. MWITS"MI August, 1999 pnwpa WELL PERMIT LOCATION MAP EXAMPLE SHOWING ALL SOURCES OF CONTAMINATION WITHIN 200 FEET OF PROPOSED WELL Copies of the tax map pave for your property can be obtained at your Town Building Department . and the Putnam County Dept. of Health F,'UST�S sw O a m v I �j s r 00 ,a 35 `'. 1.7 Ile 1.47 l:C '1 0 D• D '91 C t "1 Ile / s /or m / SS .� NA In cz Sk LA 56,E ��x' � / a� /. / m � •°i sa g 0