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BOX 31
05 I-J
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
�-- �J - ✓ APPLICATION TO CONSTRUCT A WATER WELL
please print or type PGPer
Well Location
Street Address: Tow illage: Tax Map #
Map Block Lot(s)
Well Owner:
Name:
Address: /
/e Alt
Phone M
;�
e
Use of Well:
t -Resid ntial _Public Suppl 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 Est. of Daily usage gal.
Replace Existing Supply Test/Observation Additional Supply
Reason for Drilling
New Supply (new dwelling) :4ZDeepen Existing Well
Detailed Reason
C, ' Fe-
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ....................................................... ............................... Yes . No
Is well located in a realty subdivision? ........................................... ............................... Yes _ Nom
Name of subdivision Lot No.
Water Well Contractor: Address. t." &-y-4 e CS it
Is Public Water Supply available on site? ....................................... ............................... 1yes _ NoLLLC�s
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.
pp�"�
Date:: .IQ ._ . , I �. 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 Countv Health Deoartmei
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 Commissioner of Health. 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 It/ 311J- Permit suing Official:
Date-of Expiration )1/ /1 �- Title: 4-1n,
Permit is Non - Transferable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -9T
Rev. 3/06
_ SHERLIITA E61VII..ER, MID, MS, FAAP
�-� �•= •' t ;`birirnssiorrtrriifNz'Ea�`e�'t ...:�::_... •.•• .;..
]LORE'II I'A MO LIINARI, RN, MSN
Associate Commissioner of Health
January 12, 2005
Tasche & Laurie Pietris
61 Tanglewylde Road
Lake Peekskill, NY 10537
Dear Mr. and Mrs. Pietris:
DEPARTMENT" OF HEALTH
1 Geneva Road, Brewster, New York 10509
ROBERT 3. II ®N ®I
Re: Addition — Approval - Pietris
No Increase in Number of Bedrooms
55 Tanglewylde Road
(T) Putnam Valley, T.M. 83.73 -1 -33
I have received and reviewed the plans for the proposed addition to the above mentioned
residence. The proposal for the addition has been approved as per. plans bearing the approval
stamp from the Department dated January 11, 2006. The addition is approved with the following
conditions:
1. The total number of bedrooms must remain at two without prior approval by this .
Department.
the- existing sewa g? disposal- systems:nnud' ts._expan.siorrareµ - m.ust be
maintained.
3. All plumbing fixtures must be updated with water saving devices (i.e. new low flush
toilets, restrictors for shower heads and faucets etc.).
4. The approval is for the proposed changes only. This approval does not validate any
construction shown as existing that has not obtained proper approvals.
Any other permits or variances required are the responsibility of the applicant and the
jurisdiction of the Town of Putnam Valley.
If you have any questions, please contact me at your convenience.
Ve truly yours
seph S. Paravati Jr.
Assistant Public Health Engineer
JSP:cw
cc: Building Inspector, (T) Putnam Valley
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648
r
SHERLITA AMLER, MD, MS, FAAP
_ Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
U
C
ROBERT J. BONDI I
County F,xecutfve
DEPARTMENT OF HEALTH �;� L
1 Geneva Road, Brewster, New York 10509
I /a6
ADDITION APPLICATION RESIDENTIAL ONLY
STREET55 IW\qkW/ j j&t. I J TOWN PLtAV1Q� V�I(CTAX MAP#9'3, q3— 1-33
NAME 1664\e - 1-LaU.n-C j I '6Jr15 PHO k'i (aql -C 3 PCHD# 0J ..
MAILING
ADDRESS
L K. A-W, Sfcr l ( 10
DESCRIPTION QF n
ADDITION 1C�� 5� d(3r�nfC (V\Q 0,M tirl ov-\01 I OQr SpaQ)
NUMBER OF EXISTING BEDROOMS_,l 0 PROPOSED # OF BEDROOMS
(FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPE TOR)
"Any addition which is considered a bedroom requires formal approval of plans (Construction permit)
prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of.the
Putnam County Sanitary Code.
Please submit this form and the following to Putnam County_Health Dept., 1 Geneva
B`revvster;_ - f0509;- Phone:($45) "278 =6130. ...�- ......Q� _..
1. Certified check or money order for $100.00.
2. Sketches of existing floor plan (drawn to scale, all living area including basement)
3. Two sets of proposed floor plan (drawn to scale — with name, street and tax map #)
*Non - professional sketches are acceptable
4. Copy of survey showing well and septic locations to the best of your knowledge.
Include date of installation if known. Label all wells and septic systems within 200 feet
of the property line. Contact. this office with any questions.
5. Copy of Certificate of Occupancy from Town or Certification from Building
Dept. with legal bedroom count of dwelling.
OFFICE USE
COMMENTS
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
SHERLITA AMLER, MID, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
PUTNAM COUNTY DEPT. OF HEALTH
1 GENEVA ROAD
BREWSTER, NY 10509
To Whom It May Concern:
ROBERT J. BONIDI
County Executive
Re:
Residence
TAX MAP# 6 3•-) 3`
TOWN PLMAM-V-4��Ll
According to records maintained by the Town, the above noted dwelling,
-C-OMID L,IANICE WIri-'I'& TOWN. CODE.
IS NOT IN COMPLIANCE WITH TOWN CODE
(LEGAL, BEDROOM COUNT IS 2, �
This information has been obtained from:
CERTIFICATE OF OCCUPANCY: Pt-- tJ
OTHER:
.bpft Building Inspector
f 21
Date
CERTIFICATE OF OCCUPANCY Water Su
lm PP1Y Section (845) 225 -5186 Fax (845) 225 -5418
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
NSW.
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PUTNAM COUNTY DEPARTMENT OF HEALTH
- ...... �. c �" HOUSE PLANS APPP,OVED FOR BEDROOM COUNT ONLY,
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IGNATURE & TITLE DnTF
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' CRRTIFRCATE.. 01? OCCUPAKCY Addition /Alteration
Gertifica>*e of-- OccuQancy.Io. 42 ®279 4�pplic�tion 'RTo. 92 °836 X
{`cat>on; -of Premises 55.Tan lew lde Road o'M,#83073m1-33 :;:
4 ' Ta la�& i� e. Petri .' ®�61. Teti le ylde. Rdo Lake PeekskiU.NX , ham
.. .. ........ ..... ............:... ... ...........
heretofore filed ,an a plication, fora buildin& p0mit pursuant to the Zoning Ordinance, Sanitary
�f -
C6d'e and the Yaws., effect i><i -the To*n of Putnam 'Valley, Putnam County, l�Tew: York," having
r rA " paid the
required. therefor and the undersigned having by personal inspection ascertained that
�. "thekepplicant has subsequently proceeded with the erection or improvement of the ,,proposed struc- .
tui aa,_ compliance with, the requirements of .the laws as aforeriientioned and , that, the.. said work
and: materials met every requirement of the laws as aforementioned 'aad iliat' the premises have
now been fully completed and are read for occupancy pursuant to the, provisions, of law, Now,
therefore, this certificate of. occupancy as hereby issued under the seal of the Town of Putnam.
Valley this ..... ...... day of ....... JNiy ...................... ip.. 92
Not valid unless signed in. ink )y a duly au ore agent I DWK ® NEW , RK �BEY
of 6 d under the seal of the . Town of Putnam Valley.
By......................................... ®:
DRUMS DSTSCTOR:. -2
CARLOS E.L$C -INC.
3 HUDSON STREET
1ARRYTOWN, NY, 10591
_.._ <... 1
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LTC. @.33635
GENERAL MANAGER
certificate must not,b.e_oltered_ n ony.monner; return to,_the, office, oftthe Board -if,
196
Per
Inspectors- moy be. identified by •their - credentiols.-
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER..
TOTAL
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