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HomeMy WebLinkAbout4080DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.72 -1 -13 BOX 31 IN I m 1 r'� km! 'r�r '` 1 a ■��'ti Li 24 ' 1 :-.:e I d` . . 1b BRUCE R FOLEY Public Health Director December 5, 2001 DEPARTMENT 1 Geneva Brewster, New . - LGRETTA' 1viotNY A - *k.Iv:;' M 9.N-. Associate Public Health Director Director of Patient Services OF HEALTH Road York 10509 Environmental Health (845)278-6130 Fax(845)278-7921 Nursing Services (945)278-6558 WIC (845)278-6678 Fax(845)279-6085 Early Intervention (845)278-6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Thomas Bermingham 11 Ridge Road Putnam Valley, New York 10579 Re: Well Permit Application for Bermingham 11 Ridge Road, Lake Peekskill Town of Putnam Valley, TM# 83.72 -1 -13 Dear Mr. Bermingham: This Department has approved the well permit to deepen the existing well at the above referenced property. Please be advised that if site conditions and/or site plans change and/or are revised, thereby compromising the minimum required separation distances, siting approval of the well must be re- - approved by this .Department. The above well to be drilled will be required to be sampled for the parameters listed in Table 1 of Bulletin ST -19, Putnam County Health Department Policies and Procedures. All necessary Town permits for the installation of the well are required to be issued prior to well construction. Upon completion, it shall be required that the well driller submit a Well Completion Report along with water quality analysis within 30 days of completion to this office. Should you have any questions, please feel free to contact the writer at ext. 2157. ABS:cj cc: T/ Putnam Valley Building Inspector Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer P T NAM COUNTY DEPARTMENT OF HEALTH DIVffSION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION '1{'0 CONSTRUCT A WATER WELL _ lease riot or P p type ' PCPII� Peririlt WeRB Location: Street Address: Town/Village Tax Grid # . 4 L -,$- 7 /7 —SP "c apY - ° il� 1VI 3 1,-2, Block Lot(s) Weill Owner: Name: Address: Use of Wei➢: Residential Public Supply Air /Cond/Heat Pump Irrigation I- primairy 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 ➢Dy ll og New Supply (new dwelling) Deepen Existing Well IDetafled Reason o�y ` ;.,•„� C _ "© for DrMing 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: MN.'tAo ?,r Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: 11- A Town/Village Distance to property from nearest water main: / ,Ou /e Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: _0 �3 c7.1_. ^ '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 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 ell drill r c ' ied by Putnam County. Date of Issue Z S o Permit Issuing Official: Date of Expiration I I i Z 9 © Title: MkIl Permit is lion- TransfferrabI White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97