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02820
PUTNAM COUNTY HEALTH DEPARTMENT
VISION OF ENVIRONMENTAL HEALTH SERVICES
rOSAL FOR SEWAGE DISPOSAL S ':y"t -El HEI-A — . _ - , I.- - -
OFFICIAL USE ONLY
. R ( -�V--02--.,
SITE LOCATION TM#
OWNER'S NAME a e � 't� L6) t-iC-- DoP�S' e..y PHONE
MAILING ADDRESS �v '�'14i� (,� 9 L E,� ; a•,� Id' 25'
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship (i.e., owner, tenant, etc.
DATE 104 TYPE FACILITY 5,
PROPOSED INSTALLER U A 6 PHONE
PJ
ADDRESS b, �;wl f� A- L ` ,_ REGISTRATION# PL OK
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 from licensed professional engineer or registered architect.
I, as owner, r .. reported agent of owner agree to the conditioc�s stated on this form.. _
. .... �. a ... -. i- :-
SIGNATURE 'U� TITLE �'T� (L DATE l 0 Z
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 comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6 diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title /ATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 9ME
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
ROBERT J BONDI
County Executive
ROBERT MORRIS. PE
Director of Environmental Health
DEPARTMENT OF HEALTH
DRINKING AND RECREATIONAL WATER
Norman Anderson, Inc.
152 Barger Street
Putnam Valley, NY 10579
Re: Proposed Well Dorsey
9 Hemlock Point Dr. South
(T) Putnam Valley
April 7, 2010
Dear Mr. Anderson:
A field inspection was conducted on the above referenced lot by Mitchell Lee, Public
Health Technician. The application to drill a new well is approved with the following
stipulation:
1. A Well Completion Report (WC -97) shall be submitted no later than 30 days after _
the "A' a onr l o +i
- c , .p., en oy t1-.:, p: rr�uttee.
Please contact me at (845) 225 -5186 ext. 46233 if you have any questions.
cc file
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Sic ely,
%,
Mitchell D. Lee
Public Health Technician
110 OLD ROUTE 6, BUILDING 3 - CARMEL NX 10512
(845) 225 -5186 FAX (845) 225 -5418
Print Preview Page 1 of 1
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F-TParks
Right Of Ways
9 Hemlock Point Dr. 0 Lakes
i'arcels
Prepared By:
Print Date: 2/23/2010 Q 6u.fer.Laper
{- Municipal Boundaries
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Hemlock Point Dr.
ired ,By:
Date: 2/23 /2010
-- Streams
Road Centerline
- - = = =- Gartonet
"Wetlands
Ponds
0.
[] Parks
�] Right Qf,.Way:s.
[] Lake
F1 Parcels
[] Buffer; Layer :
Municipal Boundaries
http:// eparcel. putnamcountyny .comJservIeVcom.esri. esrimap . Esrimap?ServiceName = putna... 2/23/2010
Print Preview
Page 1 of 1
ired By:
Date: 3/2/2010
Streams`
— Road'Centerline
= 'Cartonet`
Wetlands
[]
Ponds.`
Q Parks
0 Right Of Ways.
0 lakes.
Q Parcels
Buffer Layer'
❑ Municipal Boundaries,
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PUTNAM COUNTY DEPARTMENT OF HEALTH
\< DIVISION OF ENVIRONMENTAL HEALTH SERVICES
• - • -.. .z f,:. : t �:. T:. �.:�3s ��Ji. �►'v1ikTEi3 WELL
t please print or type PCHD Permt# ��
Well Location Street Address: Town/Village: Tax Map #
Ile I �aeti-9 Pa 1� 1A 1P
f a CA 4 1, 4 Mapb Block Lot(s)
Well Owner:
Name:
Address:
Phone #:. '
coq
� .
Use of Well:
f% 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 -V pm'- # People Served Est. of Daily usage gal.
,i Replace Existing Supply Test/Observation Additional Supply
Reason for Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
;; - 1
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ........... Yes Nom_
Is well located in a realty subdivision ? .................. ............... Yes _ No
Name of subdivision Lot No.
Water Well Contractor: nj _. „_ .. ,. A.... J � .. Address �
�,r- -� , ' e � - � , • �..
Is Public Water Supply available on site? ....................................... ............................... 7 Yes _ No 1,.
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Date: (a:°`1r1�1 Applicant Signature:9,frrt�n�i
r'tKMI I I U UUNJ I KUI: I A WA I tK 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 Countv Health Department.
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 FCHD and is revocable for cause or may be amended or modified
when considered necessary by the Commissioner of Health. Any revision or alteration of the approved plan requires a
new permit. Well to be constructed by a water well driller certified by Putrem County. !/
Date of Issue %, rj �-•�- _( j� Permit IssuinjOfficial: � Lt'•��.1, -(„� ,% '
Date of Expiration , , t t Title: 1 1S' (A
Permit is Non - Transfer �i > r f) `"
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange_copy - Well driller
v� Form WP -97
Rev. 3/06
C.