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Home My WebLink About4380DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -2 -40 BOX 33 1� :1 L 'm 1 I '7 ago If i ' i AV i 3 , %, :6 F f AL I all 1� :1 PUTNAM COUNTY DEPARTMENT OF HEALTH IVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print ar type ... PQ HI),Permit, # . V!! u 1 elf Y.ociiion: street Address: TownNillage Tax Grid # S mia, 5'fILx-i- ) My Am AU4EMap 94f Block Z Lot(s) fo Well Owner: Name: I Address: V5 40jjS-AtXJJMu 1'3-7 PJ VAM 110AD OWIAJIA4 Ny 10 %2- 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 _,S- gpm # People Served Est. of Daily Usage .63 gal. Reason for X Replace Existing. Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason PtZpyiDe mt-u) ti vAT4L Sip (L6-3r(0A'4 Ha .0 AVVbW E :FA( TjAX1 bL,)t7 , Pe1X4 � for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ..................................... ............................... Yes No yk Name of subdivision Lot No. OA Water Well Contractor: Wo oeR7 oA) Address: Sr. ; E�Am VAUZT Is Public Water Supply available to site? ................. ................. Yes No Name of Public Water Supply: Town N illage , $A Distance to property from nearest water mai Proposed well location & sources of contami do o e p vide on separate sheet/plan. Date: 0Q, W, o Applicant Signatur 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 water 'ller ce ified by Putnam County. Date of Issue 0 if Permit Issuing Offi Date of Expiration u j Title: V IF Permit is Non-Transrertabte White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 ;1;.,1.4::: '--'I (E'j � A �'i ��a. `t � � ��S i � � >�';p � 3'� �1 �•� @ � � 9 � � �0/� 1 � IM' � �� ,�i BMSION OF ENVIRONMENTAL HEALTH SERVICES _ ... ,.. �T. � ._ _ : 1 :'•.: � � • , -.., -` � ACA 1<'1< � - - ®., K� � AlP LII 0 'I O ABAN�IID N� WA�'� WIELL please print or type PCHD PERMIT # 4tij yd ,, 4 `� Well Locattiorne Street Address: TownNillage Tax Grid # J56 ftk/ e7f fWK Pew VAV Map Block Lots) WeRR Ow®er°: Name: Address: V,� GoA),;Tt -la oA) I )j( . 3 -7 DAM PaID, 6�0)06 xi�-, �Yeflfl �'I�e° Drilled Driven Y. Dug Gravel Other Depth Data: Well Depth th ft Static Water Level ?J ft Date Measured Use of Well: residential Public Supply Air /Cond/Heat Pump Abandoned I- pr°imar°y Business Farm Test/Observation Other (specify) 2- seeondairy Industrial Institutional Standby Water Well Contractor: Name: Address: P� Reas®>m Fo >r I LL- �J L super Abandonment Description of Work To Be Performed: Date: ° 6',S� - D Applicant Signature: \ill This 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 and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the i o ation delineated on the application for this permit has been completed. sly-- - Date Issue Permit Issuing Official Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 Free@nce' Town Lines Ej Parcels Old Parcel Lines Streams .Lakes and Ponds Wetlands Carmel Road Names Kent Road Names Patterson Road Names Philipstown Road �L-. Names . ti Putnam Valley Road Names Southeast Road Names 0 Disclaimer: Page I of I PRINTOUT TITLE ELI I http://imsserver.putnamcountyny.com/Freeance/Client/LandRecords/PrintFrame.htrnl 10/14/2004 11°00 5 300►►° oo0 2 b 90 5 9 ? ?s® 0 b 5 -o-00 ?0 5 -o- 2►►° ek, 9 1110111 R 1111�� F TRANSMITTAL t`-: ..:.r. .. FS. \: 7'.•.c+ e � .c-. u rw .ti V: _�.ey' ✓'-'Fr. ._ ... i.". CRONIN ENGINEERING P.E., P.C. The Lindy Building; Suite 200 2 John Walsh Boulevard Peekskill, NY 10566 914 - 736 -3664 Fax 914 - 736 -3693 Michael Budzinski, P.E. Director of Engineering Putnam County Department of Health 4 Geneva Road Brewster, NY 10509 r •'3� '_.;,;,�..:r:.� 1.,...;a :.. — �' -. .. _ . ......,..i;,�e ".tea:;.. �.�'::..,�.,:�.�.�. September 30, 2004 RE: Replacement Well, TMD 84 -2-40 Mill Street, Town of Putnam Valley THESE ARE TRANSMITTED as checked below: FOR APPROVAL FOR YOUR USE ❑ AS REQUESTED ❑ FOR REVIEW AND COMMENT ❑ PLEASE REPLY REMARKS Find enclosed the following for the above referenced project: 1. Two copies of the new well, location _plan. ._.2. Application-tu construct a`W 'w01- - _.... -_ _.. �.._ ._......�...... _ �.. _ 3. Application fee of $150. This application is for the installation of a new well to serve an existing residence located on Mill Street in the Town of Putnam Valley. The existing water supply is from a dug /spring fed well that is adjacent to the pond. The owner is currently renovating the house and would like to provide a code compliant drinking water supply. Should you have any questions or require additional information, please contact me at the above number. Thank you for your time and consideration in this matter Copy to: Val Santucci Signed: Keith Cronin Engineering, P.E., P.C.