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HomeMy WebLinkAbout2596P'ii'f'v��1 �►niati'i1 IuFNP�yi1�4kaa"1 wF 1:IIF'.�IT}a UM.tnda. d }i.tn..rscwn,�J iti.nalmh 1....1,.ry � aro,.ei � T I f: ! : FJ�g,�anexr nn, Prn� wFa(.f}9 � � - �. rMF'.'aY7 (11}'1 � .c I't nl � (�u Mr °• r 1 � �' i►6 O =11. gWv �: »bw�`'+ +1�,u'.ar "vrn — • _ TIMF I..•a B r w1 ._ �,,•,$ �«. rr G R r Dom+ • _ aF„ s • LJ wak7 a 1 roprosanC.that 1 om. wholly -ar 6 compb4aly rosponsiblo for the design and location of the .p�oposod systom(s); 1) that tho sopar to .di stcln above doecribod grill bo construdlej aSBhoGm on "trio approveo amendmant them to and ,in accordance faith tho standards. rules o 'regu 1-118.0 nom Col/nty ®opartmc11t of C."MI , an6 that on eom'Ootion thorooI a •'Cortilieato -of Construction Xomplianeo•' sotis4aetory to Oho Commimlonm of Healthcfill bo =brnMod to the Ccpartmant. and a, twitton �uarantoo wlll bo',furnisla6 the_ owns.. his'tuccom.ci%'hoirs'oi assigns by.tho buildc7. that mWI bulklor mill WMR in ¢odd 00- sting, Condition anV :part 00 ,old mwogo dispoL7l..sy6tom tlurirr�'.tho.Ror.' of tcr0 (8) y�r8 imnx�Wtoly 401tticfirq t110�at0 04 tho Isau- owso of tfoo sat 09 floe .t:ovtifiea4o of Construction Compliance of ,the 1 any repass Qhoro4o; 2) that tho.drilleS mollswmcd ol4aro WHO W loetited as n'on tlio 00provc9 plan end ghat said wall Will bo Install m n h the arcdtirds, rubs and rcgd a one ,of. Oho Putnam County O rt of.. "With. ®ato 4 . 6 St6nod P.E. .!" R.A. Addrox w. Ueanso No APPROVED FOR CONSTRUCTION; This approval eupiros two y6ars from the Btlto , issued .un)ess con ruction of the building .has boon undertaken and is rwocablo for muse or may Do' aniendod or moaifi68 anon considoiod nccesmr e- GOQnmissionor of Health. Any chango of anaatbn of construction roquir _.A.Q0tV po►mit. Appro�lved for ois�os�l o4 tlomo��ic^. t— onit�i 7ry�soarage��pv�llyte�7dto� .supply only. Rev. �•/� ®1v TRIO 10/88 it®a4o� DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT­A "WATER- "WELL ' "" _.._ _ ... ....... .__._.,_.,_, -; PCHD PERMIT 0 §-�17 WELL LOCATION treet Address Town V age City io - ,�. �� % Tax Grid Number .SZ -0-- Z -4 Z- WELL OWNER jNam9 SS L©! Mail ' ng Address 743 � , oeo /Zp &D A4 ivate O Public USE OF WELL 1 - primary ' 2- secondary � __I GidSIDENTIAL 0 BUSINESS D INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT P O ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify, U INSTITUTIONAL O STAND -BY Q AMOUNT OF USE YIELD SOUGHT 19� gpm /# PEOPLE SERVED /EST. OF DAILY USAGE _gal REASON FOR DRILLING 13 REPLACE EXISTING SUPPLY O TEST /OBSERVATION Q-NEV SUPPLY NEW DWELLING)- O DEEPEN EXISTING WELL GE ADDITIONAL SUPPLY DETAILED REASON FOR DRILLING SE, WELL TYPE RILLED O DRIVEN DDUG O GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES L--'NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: i IC—CX)eM Ems- - Lot No. G? WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES `r NO NAME OF PUBLIC WATER SUPPLY: " TOWN /VIL /CITY - DISTANCE �40 - PROPERTY.._ FROM - NEAREST: -WATER MAIN.:- _.. ^.._:._.._; LOCATION SKETCH_ & SOURCES OF CONTAMINATION PROVIDED N SEPARATE SHEET C_ dat ' signat re PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of 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 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 attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in.such a manner as not to degrade or otherwise contaminate s or groundwater. Date of Issue: Date of Expiration 19 Permit Issuing Official ••------ -__.._ Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller Oi PUTNAM COUNTY.DEPARTMENT OF HEALTH ... _ D. IVI- SI- ON---- OF..,EN-VIRONMENTAL. HEALTH SERVICES Date 7 Re: Property of cI C� ► S�tC�L. V.rrc.xYVnI Located ate� pp / C, ACAW!gt4A (T) G, V� 4'� Section 4 Subdivision of , :52. O Block 2 Lot Z_ C � e Subdv. Lot # Filed Map # Date 3 Gentlemen: This letter is to authorize /', J/Zd�ls�GJ a duly.licensed professional engineer v or registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in . connecter :on_w,- th_..�h :.ma,t -ter and to. .supervise the construction-of said system or systems in conformity with the provisions of Article 1.45 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very truly yours, i Signed Countersigned: OwneP of Property P.E. , R.A. , # 6 �1►-�� ����� Address -PC Box Fs-0 C Address Town 4/ L) JqA-4 0 a Telephone Telephone J�� P'C -1 PUT NAM COUNTY D E PART M E NT OF H EA LT H APPLICATION FOR APPROVAL OF PLANS FOR A WWASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: e �5 & Lo / 24 3 2,0!38a `7T a4p- �p2p hJiL�St y %03 2. Name of Project: L0 Z-- 3. Location T /V /C: h 441 iJ 4. Project Engineer: 5. Address: Sox 'Ccs-tp License Number: 5��� Phone: -L7 0 6. Type of�o_ie_ Private /Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted �-�✓ 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. t. 9. Has DEIS been completed and found acceptable by Lead Agency ?' 10. Name of Lead Agency = 11r Is thi�s--pro'j-'ct--•:',n. an area ender- the- contr ©1 oi` loca-l- p.lann-ang, -- zoning-, =.. - - - -- orother officials, ordinances? ......... ............................... 12. If so, have plans been submitted to such authorities? Ve- S. 13. Has preliminary approval been granted by such authorities? e-i Date Granted: 14. Type of Sewage Disposal System Discharge...... • Surface Water ✓ Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ........... ............................... 17. Is project located near a public water supply system? 0 18. If yes, name of water supply Distance to water supply 19. Is project site near a public sewage collection or disposal system ?..... l �' 20. Name of sewage system i Distance to sewage system 21. Date test holes observed: 22. Name of Health Inspector: 23. Project design flow (gallons per day) ....... ............................... (!�03 11/93 2. 24. Is State Pollutant Discharge Elimi.nation_System ( SPDES) Permit required ?.. 25. Has SPDES Application been submitted to local DEC Office? ............... 26. Is any portion of this project located within a designated Town or-State. wetland? .... ..........................�S:.K 27. Wetland ID Number ............. ............ .......................... 11 C,-4 28. Is Wetland Permit required? .............. ............................... Has application been made to Town or Local DEC Office? ..................i<- 29. Does project require a DEC Stream Disturbance Permit? ................... 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ........ YES or NO LJ-02 - 31. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ..............YES or NO DESCRIBE: 32. Is there a local master plan or file with the Town or Village? e 33. Are community water, sewer facilities planned to be developed within 15 years? 34.. Are any sewage - disposal areas in excess of.15%.slope ?_. .... .. v.. 35. Tax Map ID Number ........................ ............................�4� 36. Approved Plans are to be returned to: ................ Applicant Engineer If the application is signed by a person other than the applicant shown in Item 1, the application must be accompanied by a Letter of Authorization. Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A 7K* deme r pursuant to Section 210.45 of the Penal Law. � I I A SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: __ _ y1I 4146 -' 'Cl