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HomeMy WebLinkAbout3571DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74. -1 -59 BOX 28 03571 M0 t laWrI4,31"G0' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ....._.._. .�...,...,_ .. . -,�. ...T:. =�; ::: -;.a;: - ._�i�ICATIOial'TO COtei$TiZUCT i8► WA7i= RV1IELL: .. �.:. _..,� . �..;; .. . please print or type C fDe Wt7a +/ .y, Well Location Street Address: Town/Village: Tax Map # St y �v y <1°'� Map Block Lot(s) Well Owner: Name: Addres : Phone #: ?�1'r � / �Z1- aS S' �✓voc/ S'f , l%9c, �lo��c., /� . Use of Well: ___�6i`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 ­z gpm # People Served Est. of Daily usage gal. Replace Existing Supply Test/Observation 4—,Additional Supply Reason for Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason A/. S ti for Drilling Well Type Drilled Dri en 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: Address•1s Si . v aO . dh 1;,p - Is Public Water Supply available on site? ..................................... ............................... Yes No`,-G- Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location 8 aources of contaminatiqn to Oe provided on separa e,sheet/plan. Date: `'f- 17Z 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 Countv Health Departmei 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 4unty. A /r Date of Issue _ .4,11-11 Permit I Date -of Expiration I _ Title: — Permit is Non-Transferable White copy - HD. file; Yellow copy - Building Inspector; Pink copy - Owner; I copy - Well driller Form WP -97 Rev. 3/06 g d POND- 90 t 45® 60. go ®.. /AU 2.73 i CAL. 4Q7-39 4".44 A CAL 502-78. A PARF4*%* cr 61 1 60 0 0 r• w•v�mi 0 O W 0 p .. -. "c" .a �..:` :o: ..ors• y.... -.y. sew OPEN PORCH \\ \_ PEN PORCH � •1 U r i 2 STORY 2 Q ASPHALT FRAME HOUSE W Q. O \ ISTY < v a \ �/P,v AS PHA[. T I x F STORY I wood 1 \ DECK I t \ / ANCHOR Lai � IQ POLE I I I I I o I I o I I I I I I I I O I I I I J � I � I I � I I I I I Iel • � ICI l3 /. SBERLITA AMLER, MD, MS, FAAP Commissioner of Health ROBERT MORRIS, PE Director of Environmental Health Norman Anderson, Inc. 152 Barger Street Putnam Valley, NY 10579 PAUL ELDRIDGE County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Subject: Proposed Well Maiuzzo 225 Wood St. (T) Putnam Valley April 14, 2011 Dear Mr. Anderson: A field inspection was conducted on the above referenced lot by Vincent Perrin, Public Health Technician. The application to drill a new well is approved with the following _ . s.tip;ilat:oj:. _^ _ 1. 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) 808 -1390 ext.43131 if you have any questions. Sincerely, 4cent Perrin Public Health Technician cc: file Office (845) 808 -1390 Fax(845)278 -7921 r Q OPEN 131J PORCH \\ PEN PORCH I- 2 TORY z O I ASPHALT i U FRAN%E HOUSE _ W Q. TRuK \ \ ST Q ISTY 4 4 ZE STORr' ASPHALT I � \ F I \ \ \ O \ 3 WOOD DECK I I W WA NCHOR I I Q POLE I i I I < < �C',v, , I J J I I I I I I I I �I I IL Q