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HomeMy WebLinkAbout2994DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.17-3-36 BOX 25 1 few me tip* `i . 411. qA ti' I .a I ol L me 02994 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISIONi OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL picasi print oriype_ : , - 1,. ...e ... -.: o..._:.�� PCHD Permit # .f. ) q;p" Well Location: Street Address: Town/Village Tax Grid # -- 3 - 36 32- vt—=� amt 'tom"' v% AN,, \Ao-, .) Map Block Lot(s) Well Owner: Name: Address: to5°N 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 S' gpm # People Served Z• Est. of Daily Usage 150 gal. Reason for k Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason Low WATG2_ for Drilling Well Type _ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No x Is well located in a realty subdivision? ...................................... ............................... Yes No :4 Name of subdivision Lot No. Water Well Contractor.VipgHAto A�IhiEr p t,,k Address :W6,P_C F_iZ Is Public Water Supply available to site? .................................. ............................... Yes No K Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be r vit on separate sheet/plan. Id laatealr 1�..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. 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 P; % C/ Permi Date of Expiration . • Zoe Title: Permit is Non- Transferrabl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 __N_- cooL4 (70 t l� 5 -- __�.__....._......__..__... Cn LOT - - - - -- - - - - -- -- - - - - - -- - - -- f i Td ox --_.._ _________._..__...___....-.-.-...._.......__........_._...._. .........,_._._..........___... i1 ...... .... ...... Pie ----- ----- =Zzw" .... ..... . . rZ zt. z7eg r f�rh..l� . , FIJI id ......... . . .. jr . .. ...... . : X.. . ......... .61 % EiK YAP ti. 4 N �t S TARI/lEVV AVENUE. of �t TAX -.�fAP �.�s'iGN.�jio.✓ .s�'yio.✓ sa � <oce t ' ti. 4 N �t S TARI/lEVV AVENUE. of /.2£MLSSS ._s'NOwA/ I&X42,V BG.dG LQ* /1- 212, 243 4 2.y PICT .S'NOA/A/ ON A M.O0 6.v7'17-4 O "A44o of CAMP 400-011) SA[D A✓AF L✓A't F/L E-O /.V I-W-- O�jiGC of 7Wr coUNTy c�sv_r� PUTNAAe eao ,ZWA,WEL /t< y A3 Ae'l- A— 73e- SURVEY OF PROPERTY FOR liG.t/ET.4 �i CURT A�TENBURGER SITUATE IN THE TOw,✓ Of PU%NA.N ✓,OLLiy PvT.✓,eM COUNTY NEW YORK SCALE: 1"= 201 SURVEYED AS IN POSSESSION TAX -.�fAP �.�s'iGN.�jio.✓ .s�'yio.✓ sa � <oce t ' = Zz.S29•zS.s•F. CERTIFIED TO: Certifications hereon are valid for Bank, SURVEYED: /L 2� /9Y7 Title Co. b Owners for this transaction BROUGHT TO DATE only. Certifications are not transferable to • subsequent Bank, Title Co. or Owners BROUGHT TO DATE All certifications hereon are valid for this map and copies thereof only if said map JOHN SALVATORE ROMEO copies bear the impressed seal of the sur. r- Con.sulting Engineer & Land SurueyO veyor whose signature appears hereon. I NORTHRIDGE ROAD is hereby certified that this survey was PE"�KSKILL. N."It Y. prepared in accordance with the existing Q� 'IQa is ep Code of Practice for Land Surveys adopted V by the New York State Association of Pro. P. E..& L. S. NYS LIC. NO. 027846 fessional Land Surveyors." ENCROACHMENTS BELOW GRADE IF ANY NOT SHOWN /.2£MLSSS ._s'NOwA/ I&X42,V BG.dG LQ* /1- 212, 243 4 2.y PICT .S'NOA/A/ ON A M.O0 6.v7'17-4 O "A44o of CAMP 400-011) SA[D A✓AF L✓A't F/L E-O /.V I-W-- O�jiGC of 7Wr coUNTy c�sv_r� PUTNAAe eao ,ZWA,WEL /t< y A3 Ae'l- A— 73e- SURVEY OF PROPERTY FOR liG.t/ET.4 �i CURT A�TENBURGER SITUATE IN THE TOw,✓ Of PU%NA.N ✓,OLLiy PvT.✓,eM COUNTY NEW YORK SCALE: 1"= 201 SURVEYED AS IN POSSESSION