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BOX 32
04194
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
April 25, 2005
Susan Kuefner
34 Saratoga Street
Commack, NY 11725
Dear Ms. Kuefner:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Re: Well Permit Application for
Kuefner, — 59 Traverse Road
(T) Putnam Valley .
ROBERT J. BONDI .
County Executive
This Department has approved the well permit for Well #W23 -05 at the above referenced
site. 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 70 feet from on -site and/or adjacent subsurface
sewage treatment system areas.
3. The well shall be installed with a minimum_ of 71 feet of casing.
-- - 4 —A-n ultra- vicrlet,light disinfection- unit shall be-installed-on-the incoming 'Well •line-- -
to 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 to well construction.
Should you have any questions, please contact this office.
Michael J. ]
Director of
MJB: cw
Cc: C. Santos, (T) Putnam Valley
Norman Anderson
Insite Engineering
Water Supply 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
10
PUi'NAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION PTO CO , §TI' 1V( TA WA'T'ER WELL _
please print or type PCHD Permit #
Well Location:
S ee1t1 AddressA Town/Vil age Tax Grid #
S 19
i
Vli it `� 1 1 MaR'&S -0 Block 1 °Lot(s�: ; 3
Well Owner:
e-
Add 1
1,52mg �� � 1�,
' T CD
� 149
A
Use of Well:
_ Residential Public Supply Air/Cond./Heat Pump
IQdgatian
1- primary
Business Farm Test/Monitoring
Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought gpm #People Served ---- Est. of Daily UsageS'd d gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
5 wGl.
for Drilling
Well 'Type
Drilled Driven Gravel
Other
Is well site subject to flooding? ................................................. ............................... Yes
No X
Is well located in a realty subdivision? Yes
No
Name of subdivision Lot
No.
Water Well Contractor: Address:/ �
Is Public Water Supply available to site? .......................... Yes
No
Name of Public Water Supply: TownNillage
Distance to property from nearest water main:
Proposed well location & sources of contaminatio to be provided on separate sheet/plan.
F -! .
Date: _ l
- - - - ,Applicant Signature: -,n �.'..
_
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 ater well drille certified by Putnam
County. _
Date of Issue — 2�0.5 Permit Is hakoic i
Date of Expiration �' Title:
Permit is Non -Trans errable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Own Orange copy - Well driller
Form WP -97
/ X47?
� f
NOTE, these sketches are based on Now York State High Resolution
Approx. Location Existing Well Q Statewide Digital Ortholmogery Program (2000 Pgot — Present) and digital tax
mop Information rrom Putnam county. these sketches are Intended to show
Subject Property Approx. Location Proposed Well - approximate property linen d✓ebingx and septic systems for use in assessing
possible well locations only. These sketches ore not Intended far any other
Approx. Location SST Direction Of Ground Slope SLOPE p vpose and ore not intended to be ,colod. Prior to d0fing ony proposed
Existing SST5 Arrow Points Downhill --P- well. the appropriate surN y% designs. and permits must be obtained.
or.
WATER SYSTEM SHUTDOWN
PLOT PLAN
59 TRAVERSE RD.
T LANDSCAPEARCHITECTURE, P.C.
3 Garrett Place a Cornnel. New York 10512
Phone (845) 225 -9690 a Far (845) 225 -9717
www.Insfte— ang.00m
as. 10 -11 -04
ssw.e 1
^MaT Na-' 04183.100
TAX YAP
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