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HomeMy WebLinkAbout3780DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83. -1 -23 BOX 29 So or � 61 so `� 'ICI ', 14 ' T r' , ' I ' :ij 03780 ALLEN BEALS, M.D., J.D. Commissioner of Health RQI;FRT,XORRIS, . Director of Environmental Health Norman Anderson, Inc. 152 Barger Street Putnam Valley, NY 10579 MARYELLEN ODELL County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax 4 (845) 278 -7921 Subject: Proposed Well Kilian 16 Gilbert Ln (T) Putnam Valley April 17, 2014 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 stipulations: I.—The finished well. is.to have its casing ext:nd to at least --18 inched-above grads " 2. Well Completion Report (WC -97) shall be submitted no later than 30 days after the well completion by the permittee 3. The current well must be properly abandoned and filled as described in the Application for Abandonment 4. Well is to be completed in accordance with all local regulations. Please contact me at (845) 808 -1390 ext.43131 if you have any questions. Sincerely, Vincent Perrin Public Health Technician cc: VP, file PUTNAM COUNTY DEPARTMENT OF HEALTH L DIVISION OF ENVIRONMENTAL HEALTH SERVICES -- • -: - - – APPLICATION TO C ©NS'Ti2UCt A WATER WELL' - please print or type w-amom ermlt - � < >. t Well Location Street Address: Town/Village: Tax Map # Block Lot(s) Well Owner: Name: Address: Phone #: �l % Ky ?STi A"r,k ;! �4w Use of Well: esidential _Public Supply Air /coed /heat pump _Irrigation 1- Primary Business Farm Test/monitoring _Other(specify) 2- Secondary Industrial Institutional Standby of Use Reason for Drilli Detailed Reason pm # Replace Existing Supply New Supply (new dwellin d vc •i h 7 k f Lr z. ved Est. of Daily usage gal. Test/Observation . Additional Supply Deepen Existing Well Afor Drilling 1 11 Well Tvoe I V Drilled Driven Gravel Other Is well site subject to flooding? ....................................................... ............................... Yes _ No L. — Is well located in a realty subdivision? ........................................... ............................... Yes _ No +� Name of subdivision Lot No. Water Well Contractor: AA r 4d "IS e:)V✓ Address:�`S.� c�� rr, z✓�� �u �� �,,, (�, % /C� Is Public Water Supply available on site? ....................................... ............................... Yes _ No��._ 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: 6. 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. 4) Thee we`ll driller shall abide by allconditons of the5perrnit 5) TDunng;all we l dnllmg operations the`well duller 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 odifed when considered necessary by the Commissioner of Health. Any revision or alteration of the approved p in requires a new permit. Well to be constructed by a water well driller certified by Putnam Coup/ty., /` Date of Issue �' Permit Date -of Expiration . — Title:_ Permit is Non - Transferable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES AP - °.- - PI. ICA,TfOId' TO-ABANI3 ®N'-'-A�.".VA'FIriJIt-WELL f- '- ;:�.:._4::.- please print or type PCHD PERMIT #� -1 �1 Well Location: Street Address: TownNillage Tax Grid # 6rC•ri, edge i Map Block Lot(s) Well Owner: Name: Address: Well Type: Drilled "riven Dug Gravel Other Depth Data: Well Depth o ft Static Water Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Contractor: Name- Address: 0,1 � .. ✓' / �11 99 ll �i- �� 1ti n< Ott_ l v �► Y+v��,,,, vSri� f Reason For Abandonment: We(( Description of Work To Be Performed: � Fr � i \f'/VY``.% u� • "'�� � G✓' F� � `M1`. .cil /� en 3 �.J� ��C�. I..S ! I Date: / Applicant Signature: 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 delineat d on the application for this permit has been completed. it Date of Issue Permit Issuing White copy: HD file; Yellow copy - Building Inspector; Pink ai C t 64�//4 ial `f Title i - Owner-, range copy - Well driller Form WA -97 �q r _ ® 71 P • �e� a �l� 00 d/�p Op00 �♦ "b • 'o �.� •O C• a , ° �• +• e, s• Y° �0 O C ° °e a,o .a C e �d �p �o° ,r •0 O P Deo v�° ' Val .cj � a �op�a�e• ° o� d �8: C 9p °oo p�o.o P° f� 1 Y 4 � S �1y j �• i y ' 1} > t r i 0 ..w +MTM e�` �Z1 MI-11 d 1 e P