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Home My WebLink About2623DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -3 -8 BOX 22 02623 I 1 llo! 1 ` " " ' 1. ' l 0 w win f - � �• ' ' - I � � y y I I16 . . 02623 DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER CARMEL, N.Y. 10512 (914) 225 3641��,y APPLICATION TO CONSTRUCT A WATER WELL ��% DrUn DVDMTM a /.,7 -J� /1S WELL LOCATION Str a Address To =a1ty Tax Grid Number f WELL OWNER Name Mailing Address 42$= -7 aPrivate O Public USE OF WELL 1 - primary 2- secondary SIDENTIAL O BUSINESS 11 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP D ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify D INSTITUTIONAL O STAND -BY Q AMOUNT OF USE YIELD SOUGHT _gpm /# PEOPLE SERVED /EST. OF DAILY USAGE -SdD gal REASON FOR DRILLING EW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE i.40DRILLED DRIVEN ODUG OGRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES " <, NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Namq c�iL AdMe s /_�,- ,,...1:/,�A I l,'I A,nW_&. A� IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X -NO _ NAME OF PUBLIC WATER SUPPLY: _ -. - _ -- -- __ -- _- . - - - -- = TOWN /VIL /CI�,Y DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION O ON REAR OF THIS APPLICATION (date) PROVIDED []ON SEPARATE SHEET (signature) 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 s.hall: 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. Date of Issue: Date of Expiration: Permit is Non - Transferrable 2/87 19 19 Permit Issuing Official 1 White copy: H. D. File Yellow copy: Building Inspector Pink Copy: Owner DEPARTMENT.OF.HEALTH Division of Environmental Health ServicesF� TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914);225-3641 ' " ��` ` ` x�`�`'APPLICATION- TOwCONSTRUCT A WAfiER WEI�L� � � "��• x x •''• eeT��P' �R�j -• PCHD PERMIT UOSY -!Q_(3 . WELL LOCATION Str a Address To Aldeedce�� Z� a ty Tax Grid Number WELL OWNER -IJ212 Name Mailing Address 79-3b ,Private D Public USE OF WELL 1 - primary 2 - secondary EtIESIDE.NTIAL ® PUBLIC SUPPLY 0 BUSINESS O FARM ® INDUSTRIAL 0 INSTITUTIONAL Q AIR /COND /HEAT PUMP O TEST /OBSERVATION O STAND -BY 0 ABANDONED ❑ OTHER (specify, AMOUNT OF USE YIELD SOUGHT_ gpm /# PEOPLE SERVED "` /EST. OF DAILY USAGE gal REASON FOR DRILLING EW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION C)REPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING' WELL TYPE ®DRILLED DRIVEN ®DUG ®GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: N S. IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED O 0 REAR OF THIS APPLICATION ®ON SEPARATE SHEET _ j;41V_1� (date) (signature) (signature) 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 Putn County Health Department. Date of Issue: 19 ermit Issuing Official Date of Expiration: 19 E Permit is Non - Transferrable White COPY: H.D. File Yellow copy: Building Inspector f Pink Copy: Owner 287 Orange copy: Well Driller POOP 6-'4 -S-"' /- 0 C�p Fe . M, R't /vk VI /V Boyd Artesian Well, Co., Inc. R.D. No. 5 Rte. 52 e"NA-10, 512- 225-3196 ?Oeo V spa sit-, DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New.York 10509 (914) 278 -6130 ...._..- .A`PPLiCATI0N"-T0`- CON `�A: wER= �E��- .�,._:.._::�.�.._�..�.,. q��.._ PCHD PERMIT # 1S WELL LOCATION 11 Street Address �/I Town Village Cit rr,�� Tax Grid Number WELL OWNER Name J Mailing Address APrivate 1 e k 1Gt p ccO Public USE OF WELL 1 - primary 2 - secondary RESIDENTI D BUSINESS ® INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PI ' O ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify, b INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT _gpm /# PEOPLE SERVED /EST. PfREPLACE EXISTING SUPPLY O TEST/ OBSERVATION 13 NEW SJUPPLY NEW DWELLING ® DEEPEN EXISTING WELL OF DAILY USAGE al Li ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE I U-8 DRILLED DRIVEN []DUG OGRAVEL. OOTHER IS WELL SITE SUBJECT TO FLOODING ?. YES k NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name Dyu c CSlQv1 1,L Q1Ce1'M1�,..-Addressd%S_. QffS�L 0-0L'V-t' IS PUBLIC WATER SUPPLY AVAILABLE TO SITE YES y NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY .DIS'IANCE..TO. PROPERTY_ £ROM.;NEARE T. WATER..MAIN.:.w� LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED OON SEPARATE SHEET - '�,. /�� -�yi�] •�� U\ 22 (date) (sign ure) 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 otherw' a ontaminate surface or groundwater. Date of Issue: 11 12A 1947 Date of Expiration 19 Permit -Issuing Official Permit is Non- Transferrab e White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller drainage and prod 'rivewoY , lrg, exshnq R .tir i� .. ) !ermg details see construction dwP1,,•nv v on file with the Pulnom p/onnlrip - ficwrd. - /,1.3 � °- � 4 -�° ®. � �' `3 :/ � • - � v.rrsl;nq ✓0 rl .... .� f , well house r 0} `Ot• _ ? Ncle No individual oPQ 14coo( 5e - G o d e lle d t o b /. r �xisl /ny , lerat /s F covr ct-0 ' 3 "fir No� = /5 ' 50 83.56 �. B8.68 ;b : 35° 00 '� c� , T., V 0%ILlJp .- ,i j of rod /n I �• dwelling mll o/ ran... , _ Vt O �...__ -- - -- �`- ° � �• � . - � � . Opp N 2C .IM 'erpsfa, the ck (Iyp% seems M / N O � pQ _ �, ate-. h'' �•nnv °/ r�1 � _•�; � ,r, , � - �s o. p Asti Itio9 pt. rr�ly gorogel 'o� - -i water - i — - existing ' >.. C __ , existing cWrox. .:'�w � :nom traveled am �, s loroGB tank n --F �. ^ �. way to be , OF e . O_ Srt1. '" - abandoned: - _ IZ, scar/fled �� O O �.� // and seeded_ r / dwetling / o OPproxlmole la. of sprinq to lots of Wrccopee lArev= IP.,Oc3 QC'f abandoned and ` with indivrduo oxcept for burp, L't _ J DIVISION OF ENVIRONMENTAL HEALTH SERVICES / �G r 225 -0330 PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OR M'S S NAME )QO P�1 `5r ®�- -'�{-- PHONE SITE LACATION TO MAILING ADDRESS PERSON INTERVIEWED e1.L f 01fi �PCHD Complaint # Name & Relationship (i*.e, owner, t, etc.) DATE PE FACILITY on PROPOSED INSTALLER v'� T2 PHA 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 fra<n licensed professional engineers or registered architect. I;L �90 *,: - �,Wgal �� s Signature & T Proposal Disapproved rocosal amroved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Subnisgion 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 canponents tied to two fixed points d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. 4,2-- Date (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owne SIGNATURE MS: RAbe (PAID)f Ye]1aw (fin BI); Pink (gliawt) to the above co 'tions. TITLE DATE 00 h .9dv-,7iy4/ Wh:,e.-,OV .6-FIA16• Z Or V" I I I vq -- jv1.5 10 Al 044r of )r/ CCO ,P4;-e Mr14 -= 0 /A/ THE RelrA14 A,( orOZ14";Y, 'F /CE At 4, e W 1_4, leg r. 4S MAR; • 17110 Al - TeIRYZ - SURVEY OF PROPERTY SITUATE IN oellWW" Y-41- Z -F PeIZAMM CMIAIrY. Aol. SCALE: 00 CIV e � moC? N 0 AREA till h`�_ `` �}�1.�rd °-,. •�.. x,� ��t �.t111.�J..��.= �'�ri��'�I "�` e'c n. •tir?`•C,:q•� �`� M %•95 f ro o 10 4B •S /.•Sa•h;� 20,00 O F ad D • 32687' ✓UC/E 22, /9BG j�'�o or nco 4d B2TiFiEO TO 60B V4TT,• M14244A/T /C MOM,- MOeT646E caeR, S SeICCESSOWS 4AVO 1OC,4S51dVV5; rNEYEr .PANS iaw1N /9regr1o1, f n4r��r�oa AB- sr�Acr (F�LB 5B�a9B- P��,v.�ccoeoA,vc� %VW44M 5MA10A eD9 OF r//E .VBiY j/O,B.0 Sr4 7e qsJ U. vF Q0FESSJ0A1AL "A10 Sl/eYE f ORS qS 4VrZ fA1e0 /J/ 71101,e "COOP F. Ae4C.r 10E -AC !LA•No S!/levB Pa." )AMES -.-Wo. R.15HJR: }: buRVEYCO Ai IH ro"ChwoM. .,CIVIL ENGINEER d bURYEYOR '�' CB. ^LGi1R RL /.YC�KSKIL�L1`I•liAAiGff b ENCROACNM[M 6 BELOW 401AOW•. IF ANY, NOT BMOWN MERLON, qr 4��•.. .r itr`.1 ..'...- ......P..UBc L fjLjC,. NO 32687 '. P.e. A5. as CLE A/A A/O)