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Home My WebLink About2604DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -2 -50 BOX 22 02604 (AL' Tea_4T %� lzp_"�wte_� a PUTNAM COUNTY DEPARTMEN ' OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES PERMIT # ae Located at Vy icc-opea- jzy,4o Subdivision name Subd. Lot # Town or Village Lop /e Tax Map 6_?_ Block Z Lot S3 Date Subdivision Approved ~--' Renewal Revision Owner /Applicant Name Vo (Z,4 Rind iz ff ULp 5 Date of Previous Approval Mailing Address 9b &oX 1 f�A L PgftJ Race Zip jo,25M ^ Amount of Fee Enclosed Building Type & / &bi l A Lot Area No. of Bedrooms 6'� Design Flow GPD /00 Q Fill Section�Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of ,/ SOa gallon septic tank and Other Requirements: To be constructed by 'Tl3 P, Address Water Supply: Public Supply From Address -- -or: _ _ . _ P my, ate,Supp)y I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date 12-13-00 License # 6;"045,� APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system 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. Appr sie- sanitary sewage only. By: l/ Title: �� Date:' 2 3 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design P ofessional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL.. _. �. please print or type PCHD'�eimlt # Well Location: Street Address: Town/Village Tax Grid # \ 92, 077 4 /1el Map !S; Z Block 2 Lot(s) 0 Well Owner: NameWC1s>0_-> Addre s: /as -ac-- 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 gpm # People Served Est. of Daily Usage _gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason j � iv 5-- 1 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: �Ti3 Address: Is Public Water Supply available to site? .................................. ............................... Yes No u Name of Public Water Supply: Town/Village =--� Distance to property from nearest water main: r-- Proposed well location & sources of contamination to be provided on separate sheet/plan. jZ Date Applicant Signature: _ - -- - - n 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. 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-TrdhsiferyAle7 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 APPLICATION TO CONSTRUCT A WATER WELL g 31� please printor tyQe _ ....._ _ -_s_ .:...: 1 p41: ma=y_ Well Location: Street Address: Town/Villa_ge Tax Grid # \/ _ 4 e Map lg 2 Block :2 Lots) S ^O Well Owner: Name: Addre s: PC 34 I JuJ. P 1. h1 ` . 1flSeC Use of Well: esidential 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 Est. of Daily Usage _gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply. (new dwelling) . - - Deepen Existing Well Detailed Reason 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: `�a-i� Address: Is Public Water Supply available to site? ...........................:..... ............................... Yes No �i Name of Public Water Supply: Town/Village Distance to property from nearest water main: r---� Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: 1 2--(3-0 0 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 app icai ntor 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 drrilling 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 revocablefor 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 Z / ,-:r-9 Permit Issuing Official: Date of Expiration Z Title: Permit is Non-TrdniferyAle7 White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 8� w/ / uY Ir Q 7),