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84. -1 -34
BOX 33
04323
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04323
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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
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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 -�,
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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)