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Home My WebLink About4102DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.73 -1 -17 BOX 31 ir ,. v r r I 1 6 'I - IN NNI ,� . ■� og; iF-.�: '2 ,- ON I NMI -� ,� , ON 04102 -1. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL . please pant o- r type F•C'rID PerlTfnt`" Well Location: Street Address: TownNillage Tax Grid #73 17 7 & M 4k J-0 t A, Map IF 3 Block Lot(s) 1 Well Owner: Name: Address: to '- -ce i(sr� I 1 G ,>�' 7 (Y 1p G►y ' /� I,v• �r. ��v C/v��v Use of Well: _(;?'-�esidential Public Supply Air /Cond/Heat Pump Irrigation I- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served 3- 5'Est. of Daily Usage !�E 00gal. Reason for Replace Existing Supply est/Observation Additional Supply Drilling New Supply (new dwelling) . eepen Existing Well Detailed Reason c9 e4 r r/ o B — 'rl to, ,, eH , ;S )6) for Drilling Well Type rilled Driven Gravel Other Is well site subject to flooding? ..................... ............................... l Yes No _ Is well located in a realty subdivision? ..i, .... ... /..�� / .............. Yes ;b, No Name of subdivision Lot No. Water Well Contractor: a%.oks Address: Is Public Water Supply available to site? ..... - ..v.`''�''` .a..�! .V' ............./� Yeses No �S fir` % %�f yY TownNillage ✓ "�/ J�i'�� tJo� Name of Public Water Supply: n Distance to property from nearest water main: Proposed well ,location & sources of contamination to be provided on separate sheet/plan. c1(�% t , �.ko Cfir►� I e+ce " 1 44., , ' -1 - )A licant Signature - Date.. /� !' pp- g C 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 Prepresentative 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 Permit Issgi , Official. _ Date of Expiratioi 11740- Title: Permit is Non -Trap ferr le White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Complaint Information d11— Log # 73-.02-20 Complaint Recieved January 10, 2002 . Received By GraaP,,Kathy. "'i-, s' ii gn;,T e J—Unassigned ' --. "6�, Complainant (Person Making Complaint) First: LISA Last: MCBRIDE Phone: 845-528-1244 Address: City: State: Zip: Source of Complaint Source: YOUNG Associated Facility/Operation.... Address: 64 TANGLEWYLDE RD Phone: - Facility Address: Location: PUTNAM VALLEY Operation Type: Nuisance (Public Health) Sub-LHU: Category: Water Risk Level: Nature of Complaint Date Complaint Water Status Needs Investigation Resolved Description: ActionTaken: PUT WELL IN YOUNG HOUSE AND NOW MCBRIDE HAS NO WATER WELL WAS DRILLED 11/15/01 r Qz 00- '0,0G Page 1 of 1 Date Printed February 08, 2002 • fi r: ; ` 'i . r?. +.'.,•< Ki:: NY:ri' {•:j ?:Y DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 279 - 6130 Far (845) 278 - 7921 facsimile bmsmittal To: 4/ ///'1- From:,` / Re: CC: Je. Fax: Date: Pages: 11 For Review 11 Please Comment ❑ Please Reply 0 Please Recycle z6= In the event of transmittal difficulties, please contact this office. ............................ 113 PUTNAM COUNTY DEPARTMENT OF HEALTH IDMSI ®N OF ENVIRONMENTAL HEALTH SE WCES P'LI ATION 'I`O CONSTRUCT A WATER WE L-L please print or type PCHD Permit #� Well Location: Street Address: TownNillage Tax Grid #73 66 -0 e d Map q3 Block Lot(s) 1 Well Owner: Name: Address: Use of Well: residential Public Supply Air /Cond/Heat Pump Irrigation I- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served -3- S Est. of Daily Usage !Ie1 00gal. Reason for Repl4ce Existing Supply est/Observation Additional Supply Drilling New Supply (new dwelling) eepen Existing Well IDetaildd Reason 4 u �.v .. � . for Drilling Well 'Type jgUrilled Driven Gravel Other' Is well site subject to flooding? ... Yes No Is well located in a realty subdivision? .........`i....... ....�/ ............... Yes No Name of subdivision Lot No. Water Well Contractor: Al /i 040,0%s ^p Address: Is Public Water Supply available to site? ...... '`� e..Q.....,Y ............. Yes _ No A �'®`��s,�/`/%s,�w- TownNillage Name of Public Water Supply: Distance to property from nearest water main: nnLl�, Proposed well�cati n & e of oc ntami ation to be provided on separate sheet/plan. ab - l4`cp�:' Date: = 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. h 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 u ' Health Director. Any revision or alteration of the approved plan requires a new permit. We be cg s cted by a water well driller certified by Putnam County. Date of Issue / jZ. 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