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03076
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SHERLTTA AMLER, MD, MS, FAAP
Commissioner of Health
LORFTTA MOLIN ► T N� t. - - - -- _._— _
Associate Commissioner of Health
ROBERT J BONDI
County Executive
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Director of Environmental Health
DEPARTMENT OF HEALTH
DRINKING AND RECREATIONAL WATER
Norman Anderson
152 Barger Street
Putnam Valley, NY 10579
Re: Proposed Well Gifford
94 Cayuga Road
(T) Putnam Valley
October 13, 2009
Dear Mr. Beal:
A field inspection was conducted on the above referenced lot by Lesli -Ann Piraino,
Public Health Technician. The application to drill a new well is approved with the
following stipulations:
1. The well is to be constructed with a minimum of 90 feet of casing.
2. The well pump and any electrical components are to be removed from the existing
well during abandonment.
" I -A -Well' Completion Report '(WC -97) shall be submitted no later than 30 days after
the well completion by the permittee.
Please contact me at (845) 225 -5186 ext.46236 if you have any questions.
cc: file
Sincerely,
Lesli -Ann Piraino
Public Health Technician
110 OLD ROUTE 6, BUILDING 3 - CARMEL MY 10512
(845) 225 -5186 FAX (845) 225 -5418
c�'AP PLI CA fl T !�`BAi�IiW�T�A W�aTll•;.�.WIE+ )LIL < =.. _�... - _ ...
please print or type
PCHD PERMIT #At'15 -0
Well ]Location:
Street Address: TownNiI age Tax Grid #
%� a $�d� �� o 4; 3 aG w
/�� A4 h7 V`t Ile
Map6.1q,3Block 1 ot(s) ,
Well Owner:
1 7-
Address:
Name:
r
�c h f C ('Co' Co
C �
�t �I �) /
�' k C1 .441 / � 1 Gd %%I L)4 / xF
Well Type:
Drilled Driven Dug
Gravel Other
)[Depth Data:
Well Depth < ?0 ft
Static Water Level
ft
Date Measured
Use of Well:
VResidential Public Supply
Air /Cond/Heat Pump Abandoned
1- primary
Business Farm
Test/Observation Other (specify)
2- secondary
Industrial Institutional
Standby
Water Well
Name :: p Address:
(" J ;^ YtnA 'h �7'1Gi E (S±y �1 �� � � Ci. ►''� � r .S'%� �H. � K nt tJ.•L[ l � y � ✓i/�
Contractor:
Reason For
Abandonment:
!! JJ %
1 h �lCl('� �tY�L �^tJc� (2�0/ Scl /,��` j
V
�(
(/ �N n5 c�'k til/u. /� �IJCitYP� /Iv��/�y�C
/
I[Description of Work To Be Performed:
Date: %� G 0 `' Applicant Signature:
c "
PERMIT
This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and /or Part 75 of 10 NYCRR
and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall
submit to the Department a certified statement that the information delineated on the application for this
permit has been completed.
Date of Issue
White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WA -97
!�\ O,e Pao?
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
• • .• ..6'ti .. ..:� +..ga. ..... "�. - .�f'_" y .Y 1 w '- -.'
_.. .... ._.._ _.._ .. .. _
i= �C'iGrfl TL "I.O�STI`t2tlCi'!j► tiii'ATER 4""7i ELL ,,
please print or type P.CHD?P..ermit # L.L
Well Location
Street Address: Town/Village: Tax Map # (a „ Z,
Ct If L4- C' A A Lh le Map Block Lot(s)
e.,
Well Owner:
Name:
Address:
Phone #:
R/
�, y g AC) �� fh bit' //f
Q'k
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.
Replace Existing Supply Test/Observation Additional Supply
Reason for Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
V, _
A a. f d ?—t" it, fQ
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ....................................................... ............................... Yes _ Not/'
Is well located in a realty subdivision? ........................................... ............................... Yes _ No
Name of subdivision Lot No.
Water Well Contractor: D J d (3g Address. % gJa rC a,, 5 ,_,y`
Is Public Water Supply As
available on site? ....................................... ............................... _ No f/
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.
D�te: G icant Signature:
.r. • A-=A 11l� , yo .fit .6L)FC
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 Degartmer
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 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 Putnam Cou�ty. A
Date of Issue 'Z! � Permit Issuing icial:
Date of Expiration 10 Title:
Permit is Non - Transferable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; brange copy - Well driller
Form WP -97
Rev. 3/06
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SUR VEY OF Pfi
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PREPARED F(
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Atnhe-q S1 77-IA 7F IN 1
Area = J. 424 So• f
map was prepared for the exclus/ve
use of and is certlfled an /y to:
HENRY GIFFORD
nRST AMERICAN 77RE INSURANCE COMPANY OF NEW YORK
but only for use in connection with their
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Notes
1. CoPmwr 2004' by BADLY & iVA7SOV, Stirveyin9 & Englneer479, P'C
A// R/ghts Reserved Unauthorized cupflcot/art is a violation of app /Irnb/e
/aw&
2. Unouthw/zed a /temtlon or addlt /nn to a document prepared by o
licensed land surveyor is o v/o/oticn of Section 7209 , Sub —D /vision 2
of the New Yon* State Education LOW. i
• .. All cmilftcatlarts are w /id for this `nap and copies thereof aHly if sold
map or copies bear the embosa�"ea/ of the surveyor whose s 1970ture
f �
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SURVEY OF PROPERTY
PREPARED FA4
HENR Y GIFFORD
517UA 7E /N WE
TOWN OF PU7NAM VALLEY
PUTNAY COUNTY
NEW YORK
SCALE 1 in. = 10 ft. JULY 27, 2004
We hereby certify that the survey &,town hereon
was camp /sled by us on .tdy 27, 2004 , that
/hie mnn wrxa GO? "ated an .,t/ /y 28, 2004
I