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HomeMy WebLinkAbout1891DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.09 -1 -8 BOX 17 T _� Wurm . r.; . 01891 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES � APPLICATION TO CONSTRUCT A WATER WELL .-- _,. ,., "-:TCHD Permit:# Well Location: Street Address: Town/Village Tax Grid # 36.9 -1 -8 18 River Road Patterson Map Block Lot(s) Well Owner: Name: Address: Karen Giorgio 18 River Road, Brewster, NY 10509 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. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) x Deepen Existing Well Detailed Reason well rennin - _ dr :. - - ---- - _ for Drilling Well Type x 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: P. F. Beal & Sons, Inc. Address: 4 Putnam Ave. ,Brewster, NY 10509 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 contaminatio o be •ov ded n s arate sheet/plan. Date: 10/25/99 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. AA revision or alteration of the approved plan requires a new permit. Well to be constructed by a water e iller cei6fied by Putnam County. Date of Issue 24-- f 1 Permit Issum' ial: Date of Expiration Title: Permit is Non- Transfe ab White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 L HEALTH DEPARTMENT _. DIVISION OF HAELTH _ _ _ _. SEWICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME PHONE SITE LOCATION ire rl "� J�'�. /36t,--s& k�- V TO MAILING ADDRESS .S4,ne PERSON PCHD Complaint # Name & Relationship (i.e, owner,tenant,- etc.) DATE 7--.w ~ W TYPE FACILITY PROPOSED INSTALLER PHONE X-S = ji-7.J REGISTRATION # 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 fram licensed professional engineer or registered architect. T J;n, All &/ - Z, fc 6� l// , Sn arz? o(:, s uli• .4 k?/"r Proposal approved 's Signature & Proposal 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 components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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, or reported agent of owner agree to the above conditions. SIGNATURE TITLE �� /�G {� DATE 19 1 5: Wiite (M); Yellnw (mn HE); Pink (Aatiamt) x 6' deep