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HomeMy WebLinkAbout3971DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.58 -1 -27 BOX 31 03971 1 61 i .., ' ��. ' =1 ' ,r. L .I , I IN r. �' I I■ ', ,' IN 03971 C:I',-.*1- 01;� -0q,-S9y -1.6 a3 PUTNAM COUNTY DEPARTMENT OF HEALTH @ DIVISION OF ENVIRONMENTAL HEALTH SERVICES ;; . -.- �..- TLIC_ _ O. C _ _. .. . s.. ER:WELli.,. - -.- ;; -....: _ AT�ON,T � ONSTRUCT A WA,T _._ .. please print or type PCHD Permit # W I to - pS Well Location: Street Address: Town/Village Tax Grid # C. Ly- Map3158 Block Lot(s)Q Well Owner: Name: Address: wo 13% i:h4 - ",1,.1 -K peeKS'Kl (l &N1 1053-7 Use of Well: �_ Residential Public Supply Air /Con&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 Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason Nd for Drilling Well Type Drilled Driven 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: Ala!�� ,2N kde,51IJ Address: 1 NA l .&$ ,(/ y Is Public Water Supply available to 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. _ ate:: � : �� :��.� .. ._ . . D �" ... `�._��'�� � � 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 1 0176 the'.- Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code anrovided . rr that within thirty (30) days of the completion of water well construction, the applicant or their designated': J representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance vet% the n, _2 ` i requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on 4sorm provided by the Putnam County Health Department. During all well drilling operations, the applic&t an&p� well driller shall take appropriate action to assure that any and all water and waste products from stieh U' 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. I k i Date of Issue Permit IssAing 0 cial :/ Date of Expiration 2 Title: *U,4_L ' �I Permit is Non- Transfe0ra White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 ve- CL ILI LI Cj -40 .... ........ /31 T'q Leo PC Lo W %.L—L-04sm, , pot",Y. ��� 35-6 e-mkL D-x - 'e'L Vos- /0 00 64 L PV C— -7—,4 3 - 3 3 c ta e-c o-4-g. c 6, (L6 C L t C 0 41-�r tv PC ee iL 3 y � E g 13 PC V' �Zur V00i . J - PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF .ENVIRONMENTAL HEALTH SERVICES JZ OFFICIAL USE ONLY if02J7 -0J SITE LOCATION 3->6 ttke PA. t v TM# 83. ST — 1 Q2 OWNER'S NAME Vl % t- L; 14 V, L VA w g L-J n A PHONE 9 —D yq97 MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # Name & R_eFat—ionship (i.e., owner, tenant, etc. DATE R/?- TYPE FACILITY 9Z: S PROPOSED TALLER 440 &t44,8 9 � A ig (; C 2 f PHONE ._.6 `4(s� i-/< RI) I ADDRESS v 's-�Y/3IiY 1/,K c L6 si. N,Y, 1 9 REG S TRATION# Bt I t' Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. A / 2 E 144'M 12351d -I+ A4 F- 6"A � iC.f} G fi STS L .. F- �c.e.��s _ .QV.�rt. .� � ��o . �d�tr�t_ _��ti .. �� �- �� -� , Qi,,�a4- a��. -r-� $ i✓. Q��a�� I, as owner, o report ed a�f owner agree to the conditions stated on this form. 3 Pi©r« SIGNA TITLE DATE 'Z og— .proposal approved with the following conditions: �CD b �7 1. Procurement of any Town permit, if applicable. Submission of as built repair sketch in duplicate showing: a. Owner's name Ai_ b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved JDector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML III o II . .. - -w- �-A 14 C, c t JIL ,,I-- vo. h,, Piz e r r n� M 7Nx 1 t d ^4 1 „� is q '1of� <� x ,et x .J - � , - � wk � � ..t , {• � of �, " ,: Y a QN A a eR MY M c Na l , . A y,• )'"�` , -,;,,, vi .a re� i � },< +� "5' rr � �Q r � � S.cS y., �F! � •faj � t. 1r -.i c t tr fie": .a rr.,,�;kx, ^ :. t rat'•-.. ztit�' $... �, . Y.� u L E G E N D NOTE: These sketches are based on New Park State High Resolution Approx. Location Existing Well Statewide Digital arthakmagery Program (2000 Plat – Present) and digital tax map information hom Putnam county The" sketches are intended to show Subject Property Approx. Location Proposed Well approximate property 1hsA dwelling; and septic systems for use In assessing possible well locations only the" sketches am not intended for any other Approx. Location Direction Of Ground Slope SLOPE purpose end are not intended to be scaled. Prior to &&ling any proposed SST Existing SS75 Arrow Points Downhill well, the cppropriate surveys, designs, and permits must be obtained. A°°°LAKE PEEKSKILL "°'"°°°° l N S' I T E SC tD- `° WATER SYSTEM SHUTDOWN ENGINEERING, SURVEYING & 1' =JO' LANDSCAPE ARCHITECTURE, P.C. °i°Aartra' 04183.100 °RA' PLOT PLAN 3 Garrett Place • Carmel, New York 10512 1AA't"pI 356 LAKE DR. Phone (645) 225 -9690 • Fax (645) 225 -9717 8..58 -1 -27 —3—it—erg..—