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