HomeMy WebLinkAbout4033DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.66 -1 -1
BOX 31
04033
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
Jeanette Mason
350 West 55th St.
New York, NY 10019
Dear Ms. Mason:
ROBERT J. BONDI
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
February 11, 2005
Re: Well Permit Application for
Mason Property — 319 Lake Dr.
(T) Putnam Valley
This Department has approved the well permit for Well #W53 -04 for the above referenced
project. Please be advised that if site conditions and/or site plans change and/or are revised,
thereby compromising the approved separation distances, siting approval of the well must be re-
approved by this Department. This letter shall serve as record of approval and by initiating
construction of the well covered by this approval of plans, the applicant accepts and agrees to
abide by and conform to the following:
1. The well location shall be survey located and staked prior to drilling.
2. The proposed well is approved 45 feet from on -site and/or adjacent subsurface sewage
treatment system areas.
sha ll ve isiailed witrs a.;linimur;, cf. 89 fee tof casing.
4. An ultra- violet light disinfection unit shall be installed on the incoming well line 10 the ' '
dwelling.
5. A water sample shall be collected and analyzed for coliform bacteria after the well is
drilled. The sample result is to be submitted to this Department along with the well
completion report within 30 days of completion of the water well.
6. All necessary Town permits for the installation of the well are required to be issued prior
well construction.
Should you have any questions, please contact this office.
Respectfully.
JU
Michael J.
Director or
MJB/ky
cc: C. Santos, (T) Putnam Valley
Boyd Artesian Well
Insite Engineering
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085
Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648
0
PUg'NAM COUNTY DEPARTMENT OF HEALTH
o r1 - -DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.i` 7 . ApPLICA7[ ION T_O rO1o1�71'RgJCT-- A- -16'AT9,R -Y�T1
please print or type PCHD Permit # ii/—,5 3 " Dy
Well Location:
Street A ess: Town/V'llage Tax Grid #
Map Block i Lot(s) I
Well Owner:
Name:
Address:
d
Aso S'S �' ; , a ylv-k Oy loo/
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 s Est. of Daily Usagel al.
Reason for
Replace Existing Supply Test/Observation Additional Supply
fllr ftg
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
for.Drffimg
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? ...................................... ............................... es No
Name of subdivision /�, �p� �/ Lot No.
Water Well Contractor: Address: —�, / /
Is Public Water Supply avai able to site? AfL- ISA 44.. No A/
Name of Public Water Supply: & *f4 h/ Town/Village
Distance to property from nearest water main: j �� f 4A 1 ,�/VAI���
Proposed well location & sources of contamination to be'provided on separate a t/plan.
Fatty: - -Applicant RigAatwe
]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 '?--11-057 Permit Is uing Official:
Date of Expiration 2-11 __0 Title:
Permit is Pion- Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner Orange copy - Well driller
Form WP -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
o r1 — DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A. WATER. WELL
q,- - please print VV or type _ . 4. _. _.... P(;HD Permit # 7 ._•o; • -
Well Location:
Street A ess: TownlV'llage Tax Grid #
-J� �y Map Block Lot(s) I
Well Owner:
Name:
Address:
nl
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 S Est. of Daily Usages al.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? .... .......... .................................................................. Yes No
Is well located in a realty subdivision? ...................................... ............................... es No
Name of subdivision Jn�- Lot No.
Water Well Contractor: Address: / . / /
oo-4W 94 �0 61t Is Public Water Supply available'
vai able to site? lf�..JV A.dN , No V
Name of Public Water Supply: {9pAK `I/ Town/Village
Distance to property from nearest water main: A4i %f &5 ,¢�! i� ,o�y
Proposed well location & sources of contamination to be provided on separate shedt/plan.
,:Date: / 4I?plicant S`gnatu_re:_ .. ..
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. ► 12
Date of Issue •?--1f _0 5- Permit
Date of Expiration 2 1 —01 Title: _
Permit is Non - Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner/ Orange copy - Well driller
Form WP -97
u 2 I`iO6'6086": -.-iO
Fi
u 2 I`iO6'6086": -.-iO
S Ll- a y v\,8 ek ESQUIRE ATTORNEY FOR 7777-777,
BLOCK ....................... LOT ..: ............... . TITLE No. --t,A-407...
SECTION ................. SH r--'C- T ...... ....... .. . . _:
)?oy A-\
' c
SURVEY OF l,Q—V.5 \C)A-) \ S ,
AS SHOWN ON a 1K9- sy%
0
SITUATED IN
!FILED IN THE COUNTY CLERK'S- MAP NO.Vb.s1w
2gtRV TEE aZ&SLS� \V:'F- 77TTI&I
IN ACCORDANCE OVITH MINIMUM STANDARDS FOR TITLE SURVEYS OF
e-INEW• YORK S E LAND TJTLE 4SSOCIATION-
N.Y.C. LIC#36181 "All 'certifications hereon are valid
RD G. M.IHALC.ZO LIC. LAND SURVEYOR for the map and copies thereof only I�SHIR,I; EW.. YQN-KERS.-.N.-Y---,-----
2 ................ if said map or copies bear the im
4_BERKSHIRq qR. Y0-NKEfZS, N.Y.S. ...
........ . ....................................... pressed seal of the surveyor whose
................................................ ........................................
signature appears hereon."
�
tu
j
,0 0
1 Ile.
�
We s-v