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HomeMy WebLinkAbout3606DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.10 -1 -25 BOX 28 IN in "N k"! IN �♦NN . r � N . �., Ir IN 03606 ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E., MPH Director of Environmental Health DEPARTMENT OF HEALTH 1 Geneva Road,. Brewster, New York 10509 Phone # (845) 808'1390 Fax # (845) 278 -7921 April 23, 2014 Andrew Rote 50 Park Drive Putnam Valley, NY 10579 Dear Mr. Rote: MARYELLEN, ODELL . Re: Addition — A- 053 -14 No Increase in Number of Bedrooms 50 Park Drive (T) Putnam Valley, T.M. 74.10 -1 -25 This Department has received and reviewed the plans for the proposed addition to the above mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated April 23, 2014. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this .Department. 2. The area 'of _f the'exisfing sewage'disposid system-,and its'expansion area must be - maintained. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc ... 4.. The approval is for the modifications only and does not validate any construction shown as existing that has not obtained proper approvals from other agencies having jurisdiction. 5. This approval is valid for two (2) years and expires on April 23, 2016. Any permits or variances required under the jurisdiction of the Town of Putnam Valley are the responsibility of the applicant. If you have any questions, please contact me at (845) 808 -1390 ext. 43261. Respectfully, Gene D. Reed Principal Engineering Aide GDR:cw cc: BI (T) Putnam Valley ALLEN BEALS, M.D., J.D. Commissioner of Health 4 ROBERT MORRIS, P.E. Arector. of Environmental health January 5, 2012 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York ' 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Town Zoning Board 265 Oscawana Lake Road Putnam Valley, NY 10579 Re: To whom it may concern: MARYELLEN ODELL, County Executive Addition Procedures and Policies Please be advised that this Department recently. revised its procedures and policies for the review of house additions. At this time the Department will not require a septic system to be updated to current codes due to proposed construction over 501/o of the dwelling's original square footage. A copy of the current Procedures and Policies is enclosed. If you have any further questions, please contact me at (845) 808 -1390 ext. 43261. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR:cw . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROCEDURES &.POLICIES . FOR HOUSE ADDITIONS Bulletin HA -1 cw /proceduremanuaUHA -1 May 2009 Revised November 2011 The determination of whether a proposed room addition to a house is considered a potential bedroom will be made by Department staff based upon: - location of the room in the house a Accessory rooms such as dens, libraries, studies, computer rooms, offices, sewing rooms, etc. may be considered potential bedrooms. b. Large bedrooms, greater than 24 feet by 10 feet, which may easily be divided by a partition wall, may be considered two potential bedrooms. C. Storage areas or unfinished portions of the addition may also be considered potential living area and/or bedrooms.. d The partitioning of basements may result in the added rooms as being considered potential bedrooms. ` e. The renaming of a bedroom may not necessarily negate its potential use as a bedroom and will be considered on a case by case basis by the Department. f. Rooms which will not be considered a potential bedroom must .meet one of the following criteria i. If the room has a floor area less than 70 square feet. ii. If the room has a horizontal dimension less than 7 feet. iii. If the room in question can only be accessed through another room with no other means of potential egress, one of the rooms will be considered a potential bedroom, if the dimension criteria for a potential bedroom is met or exceeded by one or both rooms. g. For houses with current code SSTS.'s, excluding repairs, which were approved without a waiver after December 31, 1989, the Department will allow the following rooms on the first floor of the house: living room, dining room, kitchen, family room and Jhome ofcel -Wdy. Any ether zooms beyond those listed above will be considered a potential bedroom except for rooms which meet the criteria in item 'T. 9. Any addition which does not result in an increase in the number of bedrooms will require the submission of plans (to scale), prepared by the property owner, showing the entire existing and proposed house floor plan with each room labeled. Once the review has been completed, the plans will be stamped by the Department noting the number of bedrooms, including potential bedrooms. If the number of bedrooms remains the same as existing, no further expansion of the SSTS will be required, .provided the existing SSTS is functioning properly. The Department will issue a letter indicating the total number of existing bedrooms and that no expansion of the SSTS area will- be required and that any other permits or variances required are the jurisdiction of the local municipality. If however, it is determined that an increase in potential bedrooms is proposed, then refer to #6 on the previous age. Any previous repairs which have been done on the SSTS which do not meet current code requirements do not count towards the SSTS capacity when an addition increases the bedroom count. 10. The existing SSTS must be functioning satisfactorily for an addition approval to be granted by the Department. 2. 11. The SSTS design flow for additions that show multiple kitchens, existing or proposed, will be increased by 200 gpd for each additional kitchen over one. 12. The legal bedroom count form must be completed by the Town Building Department, even in the case where a Certificate of Construction Compliance -has-beed issued by the Department. - Any addition not covered in the general outline above will be handled on a case by case basis. 3.0 SUBMITTAL PROCEDURES Prior to the construction of a building addition, plans for the proposed work must be reviewed and approved by the Department. The submission requirements for an addition permit are as follows: a) Addition Application (Appendix A) b) Permit application fee of $100.00 (Certified Check or Money Order made payable to Putnam County Health Department). Note, if the addition application requires a new SSTS, the fee is $500.00 ($100.00 for the addition application plus $400.00 for the SSTS review). c) One (1) set of house plans, drawn to scale, showing only the existing conditions. All living areas, including basement, are to be shown on the plan(s). The use and dimensions of each room are also to be provided on the plan. The plan is to include the applicant's name, street address, town, and tax map, number. Please refer to Appendix C for an example. The plan does not need to be prepared by a design professional. d) Two (2) sets of house floor plans, drawn to scale showing the proposed building addition. All living areas, including basement, are to be shown on the plans. The use and dimensions of each room are also to be provided on the plan. The plan is to include the...--- , . applicant's name, street address, Town and tax map number. Please refer to Appendix C for an example. The plans do not need to be prepared by a design professional. e) The "Town Legal Bedroom Count and Proposed Addition Status" form (Appendix B) is to be completed by the Town Building Department. fl A copy of the property survey showing the existing house, well and SSTS and proposed building addition, drawn to scale. 3. APPENDIX A ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E. Dz e�toi''of aV viunerr a- 17IMitii d ARYELLEN ODELL txlll County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 ADDITION APPLICATION RESIDENTIAL ONLY STREET Pcz"k Tr w-c' TOWN__p u f V ��f AX MA.P # W-A I " NAME d re' , Rn-k PHONE ;Z23- 211 60:1 MAILING ADDRESS ?ct "-' '-) r'� v� DESCRIPTION OF ADDITION el n ;:s *NUMBER OF EXISTING BEDROOMS 3 NUMBER OF PROPOSED NEW BEDROOMS _ * (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) "Any addition which is considered a bedroom requires formal approval of plans (Construction permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd, ... Brewster; IVY ^10509,Phone :845) 808-13W.—... 1. Certified check or money order for $100.00. 2. Sketches of existing floor plan (drawn to scale, all living area including basement, to be shown and dimensioned and use of each room specified). (See Section 3.c of Bulletin HA -1) 3. Two sets of proposed floor plans (drawn to scale — with name, street and tax map #) * Non - professional sketches are acceptable-and preferred. (See Section 3.d of Bulletin HA -1) 4. Copy of survey showing all well and septic locations on the subject property to the best of your knowledge. Include date of installation known. Contact this office with any questions. 5. Copy of Certificate of Occupancy from the Town or Certification from the Building Department with legal bedroom count of dwelling. OFFICE USE COM MNTS 4. APPENDIX E ,V .r "FM ••: �....• .....VH. .... -. ..: .✓ ..uP `C""•... _......r...,K r. �tVV. V .. �. �1Y lI: .. s.....i v .... �.p.. n-. ... ... :.4r ..s .. .✓ � P Y.� ". APPENDIX C XN BEALS, N.D., J.D. Commissioner of Health ROB.F.RT. NODS P,rt Director of Environmental Health ., DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Town Legal Bedroom Count & Proposed Addition Status Re: t"10d(V (Owner's Name) Tax Nlap # -T 4, ( 0 2-S Address: ISO 1 nL - Town: Year Built: �Q 1 According to records maintained by the Town, the above noted dwelling, is. in compliance with Town Code. Is not in compliance with Town Code. The Legal Bedroom Count is. This information has been obtained from: Certificate of Occupancy: Laik=L-ox Other: The plans for the proposed addition are considered: Addition to existing house only Teardown and/or re -build allowed under Town Regulations -4 Building Inspector Date 5. M[A.RYELLEN ODELL County Executive G ' •s 1. '* L� .:3 �/� `ter ,(�� (3 t� NNiiNi _ mogul fA ®INNN NNN ,.. " ��..�,�, � -• SIG �, p INN INNNNNNI - � I �i i iN NNNNi NNNiNN s 1;;: I•�AR���N� J ''� INS ®INNNfiNNNrI� - 'riNINN NNNNMI _ i } T®®pN. F Pi4T MM VALLEY, . ! Application Xv 16'9 l Putnam bounty; AIew work. G� Date............. ......... ..... Wr lieaith officer of= 'tlie above Town, hereby certify that oli ....... .............. the instaliati of one' �4 li'e ta}y !J qi the property ,of :..5 ¢` N is iu aocordanCe with the provisions of the A'ani: q ,the t bore Zbwn, and is in aii respec satisYaciory, and` that the infgrmetion�il on laid appiication and said+ Pfiin�t'aor `sketch Ys correct, an do leieby grant said, owner BILL OF OCCIIANCY 8ealti 4ffce i sm y,. J V1. UT, p NAM YALLE Ap cation NIP m tyjT.New Xoik.' - a te- ..... .... ..... .... ............... Pursuant to thp $aWtary Code, of )hb above Town, the unde'rsjgn6d heieby makes APPLICATION to Z-5, Z install one........ —K .. ...... -1 AJ Fame of owne z SRACE ddress.. . .... ......... h. cat gn rWF-OVf to I �8166k No ........................ x6a'bf Land Acres ................................ .. a . 0 SKETC —, Sq Maximum No." Of people expected to We facilitk ........ I .......... A Date installation vdU be' started... **tle ... wzfk;l ................... V N 0 T ICE* A -BLVE PRINT OR SKETCH showing. (1), boundiry lines of. property (2) iliiloir et6.',' (4). P ocag sod locatlon of facility;-' including draftisi MUS THM ,�&PLICATION:' Name, of, ...... ......... ..... ................. P 0. Address .(3) lakes, streams BE - PILED WITH ................ .. .......................................................................................................... Sigilature of Applicant ................... .............. .......................... .............................................. -RiEwmK.s. . ........ .......................................... .................................................................................................................... ........................................ ............................. .............. ........ . ........ ................... ......................... ................. ......................... ............ ......................................................................................... ............................................................................................................................................................................................................................................................. r Date......_ ...... 19P. TOWN OF PUTNAM VALLEY Application N9 .526 Urns ......... AP_ LIGATION FOR 'R5TJJLD1NQ-.PERN,_".T Application is hereby made to erect (alter) ............. t;-E� ---------------- . ... . ..... ----Work to start.... �VRZG= ........... . .......................................... & W'1: ----- - ----------------------------------------------------------------- -- --�-Street or Road ........ .......... -..j of Premises --- ............. Wr.g.Mt ----- . ........ BLOCK ...................... LOT ...... ---------- FRONTAGE ....... lh.�...... Depth ... Rear .... is-0 ......... i6ther description) or number of square feet_.._._... Q _&! . ........................ : ............................... ............. N-M ' ... .... ......... .................................. Ir _ .......... ..................... ..................... 7 ................ 0q, .................. ........ .............................. 0DRESS, ... il& .................................. JeA .... . ............................ rsk CONST. ROOFING _LAND_ ood Wood Shingle - _t Paved mum* Steel A;b. Shingle IDirt Brick Tile Oiled Concrete Metal Swamp rook Brook FNDTNS. I INTERIOR ILake F. Apt. Stone b Rooms, jDams Office Apt. Rooms Sw. Pools _i0concrete k,-' I Blocks Apt. Ten. Courts Station Brick Attie Open 1Piers ttic Finished OTHER BLT)GS. EXT. WALLS PORCHES Barns BASEMENT LtWood X Front Shacks Brick X Side Cottages Brick Van. X Rear Bungalows Floor Log X Encl. Electric Shingle [Phone B. In. A TComp. rnace I IField Stone Dimension of Building Width De t4 Stories T x x x X xi x Type Foundation...., 'J, Size & Use Each... Room. with Window A�ea ................... Sewerage Type_........_ Size of Septic Tank ....... &A. A Lineal Ft. Drainage ... ............ Size of Dry Wells-. ............................... Additional Information: .................... * 1-W ... . ...0 ....... .............................. .......... j .................................................. ...... ... 7. ........................................................ t1a application must be accompanied by a copy of surveyor's man afid complete plans, specifications and all infoi mation required by the Zoning Ordinance and Sanitary Code of the Town of Putnam . Valley when requested by inspector .................................................................................... the applicant, do hereby certify that the above statement an true to m "nowledge and belief. Fee $__AOT ................. Signature of Applicant .............................. ----------------- 7 --------- of Putnam Valley - Department of health - Divi'?i4iona of Saation Ni DATA SI M T - SEPARATE SMIERAGE SYST04 isd at.K ;.;P Location.. �.�.... . Il!v�'/YIF1rY,�.,�J�........ Block....��y.flr.)... Q��t �p WC kN .. ........... . . shed ............................... • Lot ......r.0 ............... e of water supply: drilled, driven, Lot Area....G..�.G dug well, spring, public Bldg. Type.. :��°'s�.. f rooms J.. Bedrooms 0. .Future ....... Occupancy... res: Kitchen- dishwasher,.....;; garbage - - e�....; Automatic laundry. V.; bath- other .......................... E FLOW: (200 gal./ bedroom)..... . (In eased capacity required for garbage grinder - �5Co)� capacity.. Q �... gal below flow l �ne; depth air space....... . material.& ai@.�ci� "otal depth... ....liquid depth...!......... width.....s ...... length .... 6. 4.. .... partition. .;lgl�.^::.....,. ? tests: 1st .......... min.; 2nd .............min.; 3rd.......... min. ail to five(5) foot /,depth. .... ..how own. s made by ....... Q.a�. ..aG..��4. bsorption 'rate 1allowed...... ...g.p.s.f.p:-d..,Chd•cked` by . „Ur ; Gallons ... 0 492 a ...... requires. ....square feet bottom ,'-Rate ............... ?,a n t nches by (describe absorption f- ield)......17a. ... ........ ............... distribution box ovide .. .. . hp+p. ZO .rye AREA AVAILABLE ON PRMiISZS ....................... Yd F. 2of ......... 1tA3NAGE OF LATtD: natural; artificial_; curtain drain ;(show. on S, (sketc'i) ­,drained usable area MUST be provided before approval may be issaed : TCH IS R -LUIRIM and must show all 'pertinent features, north point, xopkerty lines, existing structures, driveways-; water or gas linos,.. er courses, wells, springs, dry wells or drains for roof or area All CES DETbdIC14 SUCH FEATURES; C011PLLTE PLAtiS FOR AD CYUA'I'L D.RAINAGi S' ;'AGE DISPOS. 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"` ,�.. � !'ti � ,H- x, t -: t i:�l:�: tY' �: -1 k4. F r�'r r � � ` �'f ,"s� .a:`�i •i`°�^'. D tI 'R.0 1 � - ! u rp ? •. J c ii; I x• o .�dp 3 1 a/�c.�. /� ^, v2. ' '. <I ._ 4"t _� Q.M., :`•.Z �in�navr VQII2 , k r l f OBE i lAL POTENTIAL J •Rr'3k3�ik r r_ aLIED ROQ,M , BEDROfl t41 • \� P+Nj I tl fl✓ Y 0.L R. 6 y- Ya}p, - �} 2 - ',"> ._ y . _2 kYa T mswsa`t'� x r - i K ijC N E 11A Y 111 .l� L w F� f t i•F -�J1 3/ IF? 4. I '�`.'*PL,S �;, . « +. r �'� ^r t`".. •'.+a'»s. r -ter `P� -p'.. '''S: 4: ,�'''� 5 'f.:.lI :''.`2x "Xf� "" -i: i� #i1 iii: `j •f. , .. ?' . a y,Y , a4 '{s``k4, it �"" { tF-• "-� `'�':v`"�_ � `) >^ lr% -a.. �, _ �.. _.. G M -. 7 , I '� t y�l r"` A 4 1:- H- `�. %'- "`% .sF g ,:•_,.� ,t.... _';r r,:` i y-'6: t.� 5., h. s,. "fi`:• -ia . •�,'i; .:..•n i`p"t ' ` •.R ra ts...Cl 1".;n z t, ` d 1 - AV-6t:- - --- 2. .. s.._ A:,r° -•r' f "6- S �'•� ~ yl �r� i }, -'rmi. 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I i- T bi s � a> ,Y "f -s/o pO.'eG u * - .� ..,�- a t F"T OM I J s - i; ru i vimvi %.,vuiv i r uLrnn t iviLiv i yr viLmLTH USE PLANS APPROVED FOR BEDROOM COUNT ONLY 3 BEDROOMS S"3 / ALL SUBSEQUENT REVISION /ALTERATIONS TO THESE HOUSE PLANS MUST BE SUBMITTED TO THE PCDOH FOR APPROVAL SIGNATURE &TITLE WE .j PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH $�RVIC.ES., WELL COMPLETION REPORT Well Location Street Address: T,Qown/Village: Tax Maps # Map T Block / Lot(s) Well Owner: Name: Address: Use of Well: 1- Primary 2- Secondary Pesidential _Public Supply Air cond /heat pump _Irrigation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment _Rotary. Cable percussion Compressed air.percussion —Other(specify) Well Type _Screened ✓Open end casing _ Open hole in bedrock Other Casing Details Total Length '�( ft. Length below grade%ft. Diameter in. � Weight• per foot Ib /ft Materials: �-- Steel Plastic Other . Joints: Welded di Threaded Other Seal: moment rout Bentonite Other Drive shoe: Yes _✓4o, Liner: Yes L---No Screen Details Diameter. in Slot Size Length ft Dept to Screen ft Develo ed? First _Yes No Hours Second Well Yield Test ; , Bailed ^Pumped compressed Air Hours Yield gpm Depth Dilte easure rom land su ace - static (spec ) 3c� During yield test ) Depth o completed well In W. �vo Well Log If more detailed if formation- .._.. .. descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter in Formation Description ft. ft. .am suft6ce- 1> S ra ' y If yield was tested at different depths during drilling list: Feet Gallons Per Minute Pump /Storage Tank Information Pump TypeAsd6ijo4�,-6 Capacity Depth Z74 Model -S­5 o 7 Voltage ')Laa HP /� Tank Type Volume bV a tr r VUeII DrillerName 8Atldress -_: � r � YS�24 '' k. � .'� yi�35'�'y,�' Y%k.pJ' �i .t r nrc:r f..m e W Driller (si nature) W, T JJ.' C .�»..� � �fN.+=� 'x. §u ,� � -�S� 4 ����; �'1•�,�� ✓�#!q°G� NH �. : %#' �^�Ki.� �.ek�, Pum Installer Nameddressb ; : r zn� '� $frt r(stgriatyrge) r p/ m s f: Y. '4 y�� '.T .PSS: '�i: i f,� " M•�`7 ; D rk i,l,.. ;3y £� i'�Sip% £ �$:.a ax i 'Y"'wS.+ . _,:.5 ✓i- ag y'+� 3:''a .xxr TY'" 'i i.§i £ �k Y'j 3: .}�".* .. 'i xp�' �.'"%e, b¢ •Go l .S 5 },f '<i d Yx�.`. :' 'f�, �i 5. E.` A" aM°•,+y � ' �.. NOTE: Exact Location of well with distanceg to at least two permanent landmarKs to be provided on a separate sheet/pian. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL _ ee please print or type PC.HD Penmlt # 10 [ '—' d Z Well Location: Street Address:/.l Town/Village Tax Grid # /r y, -S—c� ar i% l/r Map Block Lot(s) Well Owner.: Name: ,,.J;.J C'- Vie (/ A-\ e1' Address: S� a ��r 0, �k , �,. (Jy /1�� �v- y. 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. Reason for X* Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason LO w for Drilling Well Type _} L Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No ?C Is we located marealty subdivision? ......................:........ ............................... � ...... Yes No • Name of subdivision Lot No. Water. Well Contractor: 4„ P s on Address: /J-.4 6-1!­5(-k S l- .01/1", 6,111,x Is Public Water Supply available to site? .................................. ............................... Yes No )c 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:. - � Applicant- Signature: - _a 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 Q r-o Permit Iss ng Offi ial1 , Date of Expiration Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 I t PUTNAM COUNTY DEPARTMENT OF HEALTH P 4 � ENVIRONMENTAL E A SERVICES APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT AW 1 ­0 Well Locatio ®: Street Address: 5o PAY�L TownNillage Tax Grid # °7y.1 �G� '�+ g lve- A Map Block Lot(s) Will owner: _ Name: 1\ a //� &aolo Address: Well Type: V Drilled Driven Dug Gravel Other Depth Data: Well Depth 0 ft Static Water Level ft Date Measured Ilse of Well: 1// Residential Public Supply Air /Cond/Heat Pump Abandoned I- Iprimary . Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby atelr well Co ®tract ®r: Name: Address: X52 ®vV1/� s Reason li or Abandonment: �� V" 4 I \j IDescirii don of Work; To Be Performed: o M Na M..V EVE' Gi �tk\g iv aAJ jj .. < Date: �!-Lpplicant Signature: PERMIT Tlis 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 sibmit to the Department a certified statement that the information delineated on the application for this prmit has been completed. &N q�%6 -0 Z. b Jtlud Dte of Issue Hermit Issuing ffic'al T' e Vhite copy: HD file; Yellow copy - Building Inspector; Pink copy - owner; Orange copy - Well driller Form WA -97 r,Y�r DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 22,5 -0310 APPLICATION TO CONSTRUCT.A WATER WELL PCHD PERMIT #1A�J WELL LOCATION Street Address Town Village City Tax 'Grid Number WELL OWNER e M i inq _. -Address d`jY� Private O Public USE OF WELL 1 - primary. 2- secondary RESIDENTIAL 0 BUSINESS. 0 INDUSTRIAL O PU LIC SUPPLY ❑ AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION b INSTITUTIONAL O STAND -BY O ABANDONED O OTHER '(specify: O AMOUNT OF USE YIELD SOUGHT gpm /#. PEOPLE SERVED'- /EST. OF DAILY USAGE__gal REASON FOR DRILLING O REPLACE EXISTING SUPPLY p NEW $UPP Y NEW DWEL ING 0 TEST /OBSERVATION - ADDITIONAL SUPPLY DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED QDRIVEN []DUG QGRAVEL OOTHER IS WELL SITE SUBJECT TO FLOODING? YES ' NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN. LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED O ON SEPARATE SHEET (date) (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 thirt; (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 Department attached to this permit. 3. Submit a Well Completion Report on a form requirements of the Putnam County Health 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 dril ing operations be contained on this property and in such a manners as not to degrade or oth ise ontamin a surface or groundwater. Date of Issue: V 19 Date of Expiration 19_ Permit Issuing: ffici Permit is Non - Transferrable White copy: HD Fil qOnge k copy: Owner 3/89 Yellow copy: Bldg. Insp. copy: Well Driller CMG 10l�-� a� Sheet of PUTFNAM COUNTY DEPARTMENT OFr HEALTH e .° ;y�, �: �--v- � <.'•��B'��'r5::2•�'C �' �ii" �u•' �'' �r 'L�l•'v`:iTu�r`2�`riti'I`.r�6.L iii�i.�.T�sii�` i�i?���i�i�tcl;o c ; ,. �, � HIV �jQ4 FIELD ACTIVITY REPORT .:-� y ,. ;:.n. �, .. 50 Street PERSON IN CHARGE . Town State Zip Na : TYPE OF FACILITY: e and Title ilCL� 01 FINDINGS: ��c k.aA lemn j, p 6ZtA f 4'UmArA NJ Lay ►� __ _�z�4w_� i !b� r- o- . -b a. moo. , on Gt�c. ,9 ... na y. .. -. a 0 o& n.�*.�• .r �,«: �- �c1T9 _:irk •L�.tv .'�.� ;', ox a .. o v:o: J� �! � r,- -. -. v `�:r'- .c^a: °- .. G6' ` $- �e 1( t r - - iNS ® 2 Signature and Title RFRQRT RRCFT«n uvI I acknowledge receipt of this report: .SIGNATURE: 02/96 Title; . N/F ✓OSEPH � THERE-Sf) .1 ; .BOESC/•iH,C . 94 ;k, C5 -30* 0/ w W Frome� 1 1 j QI ;i; hOl1�N H = y FIRE oz F� ... ", I j 1• rn /6, Lf,,q D .LO% SNgiViV Z- F>U!?EL /-/ %L L , !NT%/� PIJTNf7iy/ COUNT,.✓ L�LERKS OFF /CE ON /Y1Aj! 59' \ O CERl /F /EO Tc T.vE Ls.ECC ✓R %Ty TITLE L-OT 4; : {> O AN1J GUFLRF,�NJ Y CO/Y/PA�!Y ANO. THE N F GE,QgL!� q t i y /� /RST FEDERAL cSAI% /�VG,,S FIND LOF�/V - ; .: ,� O ASSOC /F7T /O/V OF G.EEii�'�SK /LG Wall r.., � j. �/F iY1 C/ Z- O /.G /ETD . "A1l ceTf.ifi`cat.fons heraon ar.e mss' id for th© reap '.rd Y D� 1n0p�I,?17-c:.cpies U!er 0 1, , if tc.i4 Mal) or cepiNs 1 .ar the +: x--pi-,hsed sen! of file surveyor vvao3G y. an tuva U,) id 1;S },ercon." , j , PREPFiREO FOR its SURVEYED & PREPARED BY BUNNEY ASSOCIATES (1:1�114 � -W OF PgrAlm. 4a' , Makzey ENGINEERS & SURVEYORS 156 KATONAH AVE 929 MAIN STREET KATONAH. NEW YORK 10536 PEEKSKILL, NEW YORK 10566 •` ;` A/o !/ 14, T. I } 71 i i' i 1