The URL can be used to link to this page

Home My WebLink About4323DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -1 -34 BOX 33 04323 rur 1 I IL I_ I I h, ' 1' 04323 ,F DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL - -- — 'please pfint of type PCHD Permit # ) 8' 03 Well Location: Street Ad ess: Town/Villa Tax Grid # r- '7 114 Map 'i . Block Lot(s) ,:3 1 Well Owner: Name: Addre�!: 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 --- -"Est. of Daily Usage A ° gal. Reason for . Replace Existing w Supply Test/Observation ' Additional Supply Drilling �w Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven 'Gravel Other Ts' well site subject to flooding? ................................................. ............................... Yes No �. Is well located in a realty subdivision? ...................................... ............................... Yes No _ 14ame of subdivision Lot No. Water Well Contractor Address: Is Public Water Supply available to site? ................................. ............................... 0 Yes No �c 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. Date:. - 4-j- il: 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 at 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 wate w 1 driller certified by Putnam County. ,/ Date of Issue � 121 L0?3 Permit Issuinfficial : _ Date of Expiration ' rJ1f /,a V, Title: Permit is Non- Transferrhble - White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller "''Form WP -91, PUT CO -UNTY DEVARTMENT Off' HE-AUTH -------- - - - - -- - DWISION OF ENVIRONMENTAL HEALTH TH SERVICES `r APPLICATION TO ABANDON A WATER ER V V >EILL fa pieaseprintortype PCHD PERMIT # —Q Location: Street Address TownNla�e �� T 6 Grid # �� ' tlBlock is fl pu'aha�nyq A Map Lots) WefllOwner: N �0tA Address: n! ,'+ i l P0110W �G Industrial Institutional Standby gWate>r WeIIl o ik>ract ®r: Name: N ®J � Address: We19 Type: Drilled.. Driven .Dug Gravel Other 1ln IIData: Well Depth ft Static Water Level ft Date Measured Ugh `off Well: -%Residential Public Supply Air /Cond/Heat Pump Abandoned fl pu'aha�nyq Business Farm Test/Observation Other (specify) 2 se�6 ndary Industrial Institutional Standby gWate>r WeIIl o ik>ract ®r: Name: N ®J � Address: t5-L S v �� I I. V0 o- IBeasonn For Fi �c p% J� ` V✓i ed G` '1(` � l esc>ription of Work To Be Performed: bkeAAkoft, Oti it e6�� "C CLV4 PUOAP 6 0VA ®146As. -6t. VVL wlhl: -zi j. sue` `G Date: S e -� Applicant Signature: PERMIT kThis permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam "County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR [ nd• rovided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall .a, . P Y P submit to the Department a certified statement that the i ation delineated on the application for this ermit has been completed. Date of Issue Permit Issuing Official Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller I •- Form WA -97 777 -�, I Q�� Xwo e — — — — — — — — — - - - - - - - - - - -- 4L • P/0. T' : ma 34 73-1-63 7.50 AC. 31. 2.16 AC. 32. t 30 1.78 AC. 'S a :C2 W 84102 30.976 AC 33 23.08 AC. fee Cb 34 63.54 AC. S 1% ;Zqb I O 35 ■ 60.28 AC. 37 2.2 AC- CAL. 624.32 Afto; f4 25 0 4 9.08 AC. ' Rr 28 / s� 28 9.07 AC, 6 a 0 �N ti 25 0 4 9.08 AC. ' Rr 28 / s� 28 9.07 AC, 1,f6k&TA -MOLINARI R.N., ROIBERTT-413ONI)f Acting Public Health Director County Executive Director of Patient Services DEPARTMENT OF HEALTH I Geneva Road, Brewster, New York 10509 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 Norman Anderson well drilling, Inc. 152 Barger Street Putnam Valley, NY 10579 May 15, 2003 Re: Proposed Well: Brancaleoni 325 Peekskill Hollow Road 84.-1-34 (T) Putnam Valley Dear W Anderson, Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed.. Comments are offered as follows: 1. An application to abandon the existing water well (WA-97) is to be submitted. If there are any questions please contact the writer at (845)278-6130 ext. 2235. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. V6 k4lAl Daniel Hadden Public Health Technician cc: Wfile PUTNAM COUN'T'Y HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES �c _r._.._..<.,.. —225-0310' PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR SITE LOCATION TM# MAnING ADDRESS c� 1 PERSON INTERVIEWED PCHD Complaint # 3.2 9' i Name & Relationship (i..e, owner,tenant, etc.) DATE TYPE FACILITY _ PROPOSED INSSTALLER — PHONE �iL Proposal (include sketch locating all adjacent wells): NO'T'E: Repair must be in sate location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or'. registered architect. 751--0u 0 W pvd c Proposal approved Proposal Disapproved 15—/o Inspector's Signature & T' 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' diam. x 69 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 r re ent of owner ee to the above conditions. SIGNATURE TITLE �, ; 3 �. PM:. finite MD); Yeuc w (Tmn ffi) a Pi r k (Ap it ant)