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PUTNAM COUNTY 'HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
- PkOPOSAL'OR . SE DISPOEA'L SYSTEM
REPAIR
OWNER'S NAME W j i f if- S- T H C 0 9 v i two, :n4 ty PHONE
SITE LOCATION �� 6XA,1 -iT- t� �-, To P2 ,S-,3
MAILING Aobmss L,o k_F_ 12 MKS k < < ( .Y,
PERSC)N--INTERVIEWED PC HD C,anplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE 2,l r92 TYPE FACILITY
6 f. ao?"
PHONE 5'Z6 _ a.57Y !�_
;Proposal (include sketch. locating all adjacent wells):
NOTE: Repair must be in same location and of -same type as original sewage disposal system.
.Different location may require submittal of proposal from licensed professional engineer or
registered architect.
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE CJ TITLE p�t C I -t DATE 57/-1,1
PIES: Rdte (FC;D); YeUcw (Tam BI); Pink (AR21=t)
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Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE CJ TITLE p�t C I -t DATE 57/-1,1
PIES: Rdte (FC;D); YeUcw (Tam BI); Pink (AR21=t)
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
Associate Commissioner of Health
January 24, 2005
ROBERT 1 BONDI
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Mr. Frank Rice
PO Box 90
Lake Peekskill, NY 10537
Re: Well Permit Application for
Rice Property — 14 Grant Place
(T) Putnam Valley
Dear Mr. Rice:
This Department has approved the well permit for Well #W92 -04 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 85 feet from on -site and/or adjacent subsurface
sewage treatment system areas.
3-- -The well shall.be installed-with a.minimum_ -o 53- .feetvof casing. t - -• - - _.
4. A water sample shall be collected and ana yzed 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.
5. 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. u =zin i, PE
Director o n ina
MJB:cw
Cc: C. Santos, (T) Putnam Valley
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
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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--APPLICATION TO CONS',Z1WCT A �V�T.ER VVLI. = -:. �` �
..� �. �. +a.. s'�.s"-� .....q'qi nn H :9 Y••:�.4'•. r-u .�- - t. ...�- y .t - ' ✓'. �.•...�.�. �..e wbRttjdl'.vs� 1 V i]4�� 1-till- -
please print or type PCHD Permit # .p
Well Location:
Street Address: Town/Village Tax Grid #
14 CRS p (,t�'. o- ri-A/n Vgli -e 7 Map n
Block r Lot(s)
Well Owner:
Name:
Address: 1, v l�,9��
f��T1 4^') Vk4i-a5z,
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 3'"�5_ Est. of Daily Usage gal.
Reason for
eplace Existing Supply Test/Observation
Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
a.-n 147 e— E,• ,-�- / f �, h
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for Drilling
Well Type
Drilled Driven Gravef
Other
Is well site subject to flooding? ................................................ ...............................
Yes No
Is well located in a realty subdivision? .....Ad :�. P P -s r��
Yes f- No
Name of subdivision Jr
Lot No.
Water Well Contractor: Address:
Is Public Water Supply available to site? ....0....�:s?.. % . .�o� ...
Yes 'No
Name of Public Water Supply: !�� �.5/Z�' /% Town/Village
Distance to property from nearest water main:
Proposed wel location & sources of contamination to be a eet/plan.
_ ._ ... . �I
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.Date: -- C! C3 -'��i-lipiic;atit�Sign�iure:�: :. -- -. �.. • -
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 fdrin
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 Is ing Off cial:
Date of Expiration Title:
Permit is Non - Transferrable K
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Ownelp; Orange copy - Well driller
Form WP -97
TIC
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P.,
L E G E N D
NOM These sketches are based on New York State Hvh Resolution
Approx. Location Existing Well L
Statewide Viaita Orthomagwy Program (2000 Pact —Present) and digild tax
mop Inft-motlon ham Putnam County These sketch" are intandod to show
'dwellIngx
Subject Property
Approx. Location Proposed Well AL
qWoAimato property 11has and sVt1• systems for use in assess(ng
pazz1ble Was location &WY- Those sketches are not Mended for any other
Approx. Location
E9
Direction Of Ground Dope SLOPE
p.,poso and are at .dsd to be scaled Prior to &NIng my proposed
Existing SSTS
Arrow Points Downhill —
wall, the appropriate swwj% design; and Permits must be obtained.
-.LAKE �PEEKSKILL,
or
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a4m 1 —11-04
KfA-TER'SYSTEM SHUTDOWN
ENGINEERING, SURVEYING &
Sc".
LANDSCAPEARCHITECTURE P.C.
FWACT NQ-* 0411U ?Do
PLOT PLAN
3 Garrett Place - Carmel, New Ina,* 10512
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14 GRANT PL.
Ph— (a45) 225-0690 0 Fa, (845) 22.5-9717
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- o: ;REVISIONS
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SPECIAL DISTRICT INFORMATION
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FOR ASSESSNEPT MOSES OILY
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NOT TO SE USED FOR CONVEYANCES
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JAMES W. SEWALL COMPANY
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