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Home My WebLink About4384DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -2 -47 BOX 33 Illaclooi J y I J Is { Ell I ' r . ; i. s - L ' �'i'' �;ri ■ Illaclooi t 7 777 A PUT' D D SP OF T NA M CO U NT HEAL H k` pivision of "Envfronmental�Hea /th 1"'N Y X10512 4: = CC- ((TFtCA TErOFk.CO1VSS?:�lT1N r1P1�N01 ,FOFSEWAGE; :DISPOSAL - SYSTEM own ia9e a � W n` Or V' Located at j r e Section �'� Block } it Z42 1 Owner Er Lot cam— ob Separate Sewerage systemkbwlt'by l0 v d� Address �� "/G f Consisting . of �_ Gal, sepfic lineal Feet.X width trench i Other requirements Water Supply " Public: supply. From , Private - .Supply `Drilled :By k Adds � �• r ��.G ' + BuJding Type, rs / G� ;4•� No of _Bedrooms' Date' Permit :Issued y.c Erosion Control Been Completed "a ^ tI Yco� eted work' copies. *of whlch are' 6 cerUfy`that, the systems) as listed serving the above premises were constructed essentially as.shown on th Mans of thfe pipJ tached) and in accordance with the standards 'rules and regulations plaits filed •`and the; per it ~' ~eSi� a�- bounty Department of- Health R R�nPCI y P.E. DV/ R A' Address ?�� -nc.� `ire '• �' @hse N .^ o •.Q 14 Jerson +occupying premises served by,`the above system(s)yshalPpiomptly take such action as ma �nec ssary, to secure t abrrectioh of any unsan(tary ;ons resultin9`from such :,usage. - Approval of the separate?"sew`erage'system' shall.become,nusl 4,'v>;a gbag•�:`�licsanitary sevrer becomes ' x :• ;.e 'and the' approval of the private water supply shall become null and vo�d.when .a •public v�� upph•,�cQ � ��e'ilable Such approvais, are ; to modification` or change when, m the- judgment�of the:Com +ssio r f Health, wch rev t� �i�U or.-change is necessary r v fi., 27, ` '� ..� t✓ gy > ?� ' Title Via• n F } P.UTNAM !� _ Qry stop flf Ehi; 1. _CONSTRUCTION .P.ERMIT FOR: St MACE -; i) - .! Located at'. Subdivis(on .. i r( Building Type�� _f /Pi1'ff p Lot Area Z G.r> Number -of Bedrooms ,1 A. ,Z Separate Sewerage System;,to consist of -ew To °be •cohstrueted' -by '�r'a�l�y v�ai�W- Water Supply Public Supply, From Private Supply to- be drilled bye i .� Address ? ,Other Requirements Ity ,Depa,rtment' u'bmitted to;the e J6 `good opera, of-the approve be located as *oi my Departmen,Et° i .6s ROVED FOR CC cable for cause'o Tres °a new perm Co an. Section Block . Address - M `F \ 1 h %W&t- P2 e:`Commissioner.of Healt'hwill assi 6y thtiuilder, that said-builder will mmetOA%pl [lowing date of the issu- 2)'. &e;driiIdd ,we II described, above I , ei-MrV , r4ula of the Putnam r• e fs �•••• �ticense No , tY , 5 s - ��build�ng has been undertaken and 'is Any change or alteration of construction„ Y R s r% '.ARTMENT OF HEALTH Services, Cas'inel Nom, Y 10512 ; T a ...Town_ or village' Section Block . Address - M `F \ 1 h %W&t- P2 e:`Commissioner.of Healt'hwill assi 6y thtiuilder, that said-builder will mmetOA%pl [lowing date of the issu- 2)'. &e;driiIdd ,we II described, above I , ei-MrV , r4ula of the Putnam r• e fs �•••• �ticense No , tY , 5 s - ��build�ng has been undertaken and 'is Any change or alteration of construction„ Y R s r% PUTNAM COUNTY DEPARTMENT OF HEALTH Division' of Environmental Health Services, Carmel, N. Y. 10512 r CONSTRUCTION. PERMIT FOR SEWAGE DISPOSAL SYSTEM 9v�"Ni9� � �i91 [ Efi Located - 74ZXA, /2'Z B Town or Village -at 5 Block Subdivision Lot I represent that I am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separa above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a'nt T _r( County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to j oT, be, submitted to the Department, and. a written guarantee will be furnished the owner, his successors, heirs or assigns "" 1W place in good operating condition any part of said sewage disposal system during the period of two (2) years imm24 HKio ance of the approval of the Certificate of Construction Compliance of the on inaI system or any repairs thereto; $ t j• quk will be located as shown on the approved plan and that said well will be install accordance with the standards, m'I�S f,d� r u County Department of Health. 1 /9 (/ x dJ .�` Date �I L ' � %Z Signed ie di :ner of Health'will I'i:`� id builder will t, a of the issu- Tt *ribed above ' f the Putnam p Ga � Address �'L.4ne /b:rz.G a. Lic G' —,�,' APPROVED FOR CONSTRUCTION- This approval expires one year from the date issued unless construction of t ha gn`�Q'eerconst and n era revocable for .cause or may be amended or modified when considered necessary y the Commissioner Health. An o a g@ or [a QQ " "34 cL construction 1. requires a new permit, fop ro or dis osal of domestic sa A ewa d/ 0 - r— c /� p� p'vats. su only. �r,90F�ss Np\ °► +..' Date By age .✓ //' -. °rar9 �i Title N YORKTOWN MEDICAL LABORA'T'ORY Il�l� P.O. Box 99 32 Kear:$ ®e4 ~ Yorktown Heights, N.Y.1039� �_�.�._ �. lis r,n �/ 20,08 143.3203._ ,' . IBI SULTS OIL iEXAIMII EAR• ,.. ATION OF WATER 5/1 YELL COMPLETION REPOR PUTNAM COUNTY DEl "AnTMENT OF HEALTH. V71 Division of Envirunnr:nta► llcilth ;.vrvicus COUNTY OFFICE UUILDING CAII&IEL, NEW YORK .FepaC is.; ta: LeeciSmpl�Y ,ed *.by- ti:«a1,drit ter- and sttI .:;it.-d d'Cot inty *F4eifth''Ucr;irtment'.id :., dr`'vlrtt'A 156o %eta y�ii�0 of analysis of water sample indicating water is of- sitisfacter•/ bacterial quality before certificate of construction eornpliance Is issued. REPORT MUST BE SUu1.111'TED l':ITHIN 30 DAYS. OF :ELL COPSt'LGTION OWNER Nye# ,�f .i ADDRESS LOCATION OF WELL (► /o. 6 Street) (Town) (toI Nun:taq PROPOSED USE OF " WELL n DOMESTIC D SUPP Y BUSINESS D ESTABLISHMENT D INDUSTRIAL D FAR1A % CONDITIONING TEST WELL D (Spe` R) DRILLING iQU1PN,EWi D ROTARY AI PERCUSSION P RCLUSS16N a OTHER CASING. . LENGTH (feet) OIAMETcR(inchas) WEIGHT PER FOOT � THREADED El WELDED (VIDIE SHO Ln' yEs 11 NO (Y. "k5 A �G c.;CjVTT-df -- "�J YES u N0 NIELD TEST D CALLED D PUMPED El COMPRESSED AIR HOU1RS 17-- G.P M. 2 YIELD WATER 1Js LEVEL EASURE FROM LAND SURFACE DURING YIELD TEST fleet) . Depth of Complrled Well In feet below Land surface: _...-•---- SCREEN .6�KE_. ' LENGTH OPEN TO AQUIFER (feet) DETAILS SLOT SIZE DIAMETER (inches) IF GRAVEL PACKED: ]GRAVEL Diameter of well including gravel pack (inches): SIZE (inches)IFROM (lost) ITO (foal) '/1 FCOM LAND SURFACE` _ 1 FORMATION DESCRIPTION :ketch exact location of well wf:h O;st3nces, to of least two permanent landmarks. fi:ci iv Vii;,; If yield was totted of different depths during drilling, list below FEET GALLONS PER MINUTE rtl.l.C�MPIt {�D ./1 DATE OF ALINIRT I WELL r)n11 E Fn tSlnnetur.% `nn YOV /y- - T.. '+7 �r r �.w7. .. �t •� ^i _. �. �..,�� =.. . ---;.. _.�. ✓i.:' =. Pft .r.Q /a v /,.�. ....:., ._�i'. .. ._.. '4 Owner or Furckfaser of Building Municipality J/ Building Cons ructed by 0 G Location -- Street Building Type ZJ Z Section O� Block Lot . GUARANTY OF SEPARATE SEWAGE SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules -and regulations of the Putnam County Department of Health, and hereby guaranty to the owner, his succes- sors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of initial use of the sewage disposal system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occu- pant of the building utilizing the system. The undersigned further agrees to accept as conclusive the de- the Division .of Envi ronmen -Bal fi-eal- th.- 3e.r -- vices of�`the Putnam County Department of Health as to whether or nothe failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this �J ,V day of 19/� Signature Title (If corporation, give name and address) d' THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. Division of Environmental Health Services, Putnam County Department of Health a T, `r`�<:, � •• A, ., -Cw ... +.., ., .,, ...:wh a -. .. _ �. ,. .T +' _, rw .1` ui '- rC�o�1.. • Y�.;;, C.r:.:..4:.... •M .. -... PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date /0-. -7Z Re: Property of . ,�, ,09o4EY C- i�A4w«.0 Located at /ge TX�x• Mi9�o /Z2 Block Lot 2c�� 2¢, Z Gentlemen: This letter is to authorize Jo.Se /O,V A' 504e.iuA-2.✓ a duly licensed professional engineer or registered architect (IndicaEe__�— to apply for a Construction Permit for a separate sewerage system; to serve the above noted property in accordance with the standards, rules or regulations as promulgated by the Commissioner of the Putnam County 'DIepartmcnt of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system.,o ,. sytem h ., ,` • t_ si,ons of,: Articie :145..or „ ... - 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Coun ersi � • ••• P. E . 4t % (Seal) Very truly yours, ` 9 Signed 11 C\,\ "X a � L � v Owner of roperty � �► r is b - aq-lti Pi��►. Address e ep one t2EVjEW CHECK SHIT D 00"OFIR MT House plans O.K. Design data sheet Peres presoaked? Kin., 30" perc test depth Cont. results for 3 .nuns D. Hole log O.K. _ Corporate Affidavit for other than individual Authorization. for engineer Letter from Water Supply if applicable Meets Std.1 Remarks 1 "Ye s ; __No If variance requested -such noted on plans & apps.; DETAILS if change is proposed, ) Existing contours shown show new contours) Slopes for driveway cuts, etc. shown Water service line location Footing - drain, etc. location Top slope, b orrr slope of fill Percolation tests and deep test pit location Septic tank size and conformance to std._____ 3 B. R. house minimum - House setback shown , FAI J_UI waL' eJ, vi Ull.Lil �)V 1 U. U1, X-_U buvwii I i Plan and profile SDS oth °r, wells and... SDS: �� oser X00 shorn c5ll reference made ) = Y. Property :boundaries (metes and bounds -- clearly shown SEPARATION DISTANCES SPECIFIED ON PLAN - 10' to P.L. 20' to Foundation walls 100' to Nearest well ✓ i 50' to stream, march, lake, etc. incl.expansion 15' to Curtain drain ! I 10' to water line (pits -20' 15' to storm drain ! 10' to large trees _ 10' from foundation to septic tank 5' to pipe floor, leader drain & footing draln � rT ,n CI'M r ;I; LIST Date.: _ Gr ^.: Ins.p.by: U,,aewoav INITIAL SITE INSPECTION Les I No ' Comments Property lines or corners found Can estimate house location . Will driveway need cut . Must trees be removed -note these . . , Is,deep hole representative of entire SDS area Additional deep holes needed. .. . . Sufficient SDS area available considering driveway cut, house Ioca.tion, separation . distances, etc. . . . . . , . . , . DEEP MOLE DATA Depth: Water elevation: Rock elevation: Soils description: Date: FINAL SITE INSPECTION Insp. by: House located where shown on approved plan. SI)s 7 nna.ted M nnrnATC0 Width of trench average Slope of tale line and trench acceptable , Room allowed for exyp r_si on trenches , Over 50 ft_. from. swamp, .y4 tercou�rse - ..._V6tural soil-a,not-stripped -or SDS area.. . unnecessarily graded . . , . . 0 0 , 10 Ft. rra1 -ained from prop line, and 20 ft. from house . Separation of trench from house, well etc. follows plan . 0 . Number of bedrocras checks gr , Stones, brush, stumps, rubble, etc. eater than 15 ft , from nearest trench . . , , , 15 Ft.. of peripheral soil horizontally from trench . . . . . . , 0. Junction boxes prope_,ly set Could surface run off from driveway, roads, ground surface, etc. channel near SDS, , area Does lot drainage annear O.K. in area of SDS " a PUT NAM COUNTY DEPARTMENT 07 HEALTH DgVllKON OIF IENWflBONM ENTAIL IHIIEAL'll'H SIEIISWCES APPLICATION TO CONSTRUCT ''� ..,� 1 :..� P .) - �-5-•. !� v f �..� 1-. -. r -. �:;..... �l' .'f) :1�r. � ..T. �• ...• . �J` .r ., r . . please print or type PCHD ]permit ,# Well Location: Street Address: wnNilla e Tax Grid # �-0q1 1 gt. ��. on !� Map Block Lot(s) Well Owner: Name: rr I Address: ) LAI Use of Well: 9 Residential Public Supply it /Cond/Heat Pump Irrigation I- prnnnary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 5" gpm # People Served Est. of Daily Usage _Bp gal. =Y= Reason for V Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason NAP {AC'S - 01 wv'i 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 Name of subdivision I Address: ��• Lot No, 1 LqWater Well Contractor: Is Public Water Supply available to site? ................................. ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water mai Proposed well l cation & sources of contamination to be p ded on s ar et/plan. Applicant Signat -ur 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 roducts from such well drilling operations be contained on this property and in such a m e eras t to grade or otherwise contaminate surface or groundwater. APPROVED ' FOR CONSTRUCTION: This approval expires years from a 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 ell dril r c T d by u County. Date of Issue Permit Issuing Pfficial: Date of Expiration t I. Zh o Title: t Permit is lion- TransfferrabRe White copy - HD file; )16 LJ Yellow copy - Building Inspector; Pin copy - Owner; 0y Orange copy - Well driller 1 I 0 � LI 0 ' �% L C.Form WP -97 Public Health Director January 8, 2001 DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 _ Preschool (845) 278 -6082 Fax (845) 278 - 6648 CERTIFIED MAIL RETURN RECEIPT REQUESTED Mr. Bradley Chadwick 25 Posey Road Putnam Valley, New York 10579 Dear Mr. Chadwick: Re: Re -drill Well - Permit # W -65 -00 Chadwick, 25 Posey Road TM# 84 -2 -47, Town of Putnam Valley It has been brought to the attention of this office that the above stated "new" well has been drilled. Pursuant to PCHD well application requirements an as -built and well log must be submitted no later than 30 days after the well completion. This has not been completed or received by this office. Please submit an accurate plan of the subject property showing the "new well' as well as "abandoned well," completed well completion report, and certification of well abandonment. Failure to comply with these requirements will result in departmental enforcement. Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer ABS:cj cc: (T) PV, Building Inspector Encl: WC -97, WAR -97 d PUTNAM COUNTY DEPARTMENT OF HEALTH DIffVffSffDN OF IENWRONMENTAL HEALTH SERWCES APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT # 4013-00 Well Location: Street Address: T own Nill e Tax Grid # ��'�� Map Block Lot (s) Well Owner: Nam . �4,d'1 es' Address: 1 U3-e Uj4� / /(' Well Type: Drilled Driven Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned 1-primary Business Farm Test/Observation Other (specify) 2-secondary Industrial Institutional Standby Water Well Contractor: Name: A e 1 �, ' n � � , . �� ,�- � 41; Cy Albandonment:. l Description of Work To Be Performed: _l �' Date: Applicant Signature: 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 information delineated on the application for this permit has r completed. 1 Ili DatJ of Isle Permit Issuing Official itle White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 7� 2000 Re: Department of Health Review of Proposed Well for Property Bradley Chadwick 25 Posey Road Putnam Valley, NY Tax Map #: 84-2-047 Dear Ms. Lein: Please be advised that an application for a Construction Permit relative to the construction of a well proposed for the cap_ tioned property has been made to the Putnam County Department of Health. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call the Health Department at (914) 278-6130. Very truly yours, --Brad T.-, Chadwick- Agent Received By-�6 Address: �'A'147 Tax Map #: ]PU NNAM COUNTY DEPARTMENT OF HEA C®I.AINII' # 798 700 49 "avO NFE DiENTIAE SE I IffQUIS'T' RiEC®RHD TOWN: PUTNAM VALLEY DATE: 12/28%00 REIFETBRIEIID TO- AS 'T'AKEN IBYi S 'T'ELEPHONE CALL: X IN PE REQETIES'T' (FROM: AT 7.AN STMMO ADDRESS: POSEY ROAD = :. :, COMPLAINT OR REQUEST' 9QN: LETTER: 'T'ELEPHONE: 528-0185 Neighbor drilling well outside.: Permited 5' >0" radius of old well. Permit W65 -00 issued New well is within 200' MOD of his septic. Of Berger Street, ACTION TAKEN TTY: DATE: FINDINGS: DYE B'ES'T' DATE: 'T M #: CONCLUSION: PERSON NOTIFIED: PC -CR -99 DATE: ESTIMATED TOTAL MAN HOURS SPEND': Code r Compla:emt: , Tn _ pNRForn%. ._ . Yes 140 BRUCE R. FOLEY 3ublic Health Director LORETTA MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914)278-6130 Fax (914) 278-7921 Nursing Services (914)278-6558 Fax(914)278-6085 Early Intervention (914)278-6014 Fax(914)278-6649 VVIC (914)278-6678 fax (914) 278-6085 To: All Well Drillers, 'censed Engineers and Registered Architects From: Bruce R Foley Subject: Neighbor Notification Date: August 18, 1999 Please find attached this Department revised procedures relating to Well Permit Applications. Should you have any questions on these procedures, please contact this office. Thank you, BRF:tn B$UC.E .Fa.- FOLEY... U Public Health Director DEPARTMENT OF 1 Geneva Road Brewster, New York HEALTH 10509 C LORETI'A' MMAkld R N.; M.S.N. _ _ -- Associate Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 , MO. Ike gif-MMULIjej Applications to the Department of Health for Well Permits will not be .reviewed until such time as the Director of Environmental Health Services of the Department of Health is provided with proof that notification of the application for construction was made to all property owners within 200 feet of the proposed well location. A location map (a tax map would suffice) with all properties shown .within 200 feet of the proposed well location must also -be provided to the Department. An example location map is attached. Notification shall mean receipt by each property owner of a copy of the attached notification form along with a copy of the latest site plan. i _.., . Proof..of.receipt of notice by property owners..can.include.either of the - following. _ 1. Copies of registered mail receipts. (Return receipts) 2. Copies of the notification form signed by the contiguous property owners. Failure to provide the Department with adequate documentation of the performance of the notice will _ .-.....result in our delaying action on the application until proper notice is executed. Transmittal of this notification should be sent to the all property owners within 200 feet of the proposed well location, by the applicant or well driller. A format of this notification form is attached for your use. BRF/RM/tn August, 1999 BRUCE R FOLEY - Public Health Director 7a DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI RN., M.S.N. Associcte Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 PROCEDURE FOR NEW `j`ELL PER-11T APPLICATIONS 1. Well permit application is to be submitted along with fee.- S 100.00 certified check or money order, for all permits other than redrills. Redrills require only permit applications. 2. Locations of all sources of possible contamination within 200 feet of the proposed well location are to be shown on a plan or tax map. 3. Neighbor notification is required for all property owners within 200 feet of the proposed well location.. 4. Feasibility of well location is to be confirmed by a representative of this.Department_.. 5. If the proposed well is within 15 feet of the property line the approved well location is to be staked by a Licensed Surveyor. If the proposed well location is within 100 feet of any source of contamination, the well location is to be staked by a Licensed Engineer, Registered Architect or Land Surveyor prior to drilling. 6. As -built and well lo; to be submitted no later than 30 days after completion, by permittee. BRF/RM/tn August, 1999 pnwpa WELL PERMIT LOCATION MAP EXAMPLE SHONVINCi ALL SOURCES OF CONTAMINATION WITHIN 200 FEET OF PROPOSED WELL Copies of the tax map page for your property can be obtained at your Town Building Department and the Putnam County Dept. of Health % LSO AC. SSd.'s ocation r4S .. =� VII '. ~` _ -• •¢ ... ., ....: ': •••, •__..__ _._ s name - � . tax may • y;, 1.49 k� s o hers n me pg IVI •uu t x map 3 proposed we ao existing we 1 —(if appal•' ole) • � 45 Y 1 r C 1.2obt, ssds 10 a n ss s oca io _,•,, u j; -�l% ers' .name E •o a tax .map i :s 44 w v � owners' name tax -map ' ssds lacatz 1.0d At. ssds locat on Jr/ % 1.0: 9 A P 51 43 I .2 1.30 RC 1.00 AC. ' 3 • �. 2 ' �, 1.40 k:. • � � 9 PUTNAM COUNTY DEPARTMENT OF HEALTH IIDnqSffON OF IEN RONMENTAL HEALTH SERW CIES APPLICATION TO CONSTRUCT A WATER WELL please print or type _ PC �� Perinit; #. �49 y A Location: Street dress: Tax Grid # _ Map Block Lot(s) Wen Owner: 0m, e: Ad ss: Use of Well: Residential Public Supply Air/ eat Pump Irrigation I -Primary Business Farm Test/Monitoring Other (specify) 2- secondairy Industrial Institutional Standby Amount of Use Yield Sought 5'- gpm . # People Served - Est. of Daily Usage S --o gal. Reason for Replace Existing Supply Test/Observation Additional Supply IlD>rnfll ag New Supply (new dwelling) Deepen Existing Well IlDetafled Reason for IlDrffinng WeR Type " Drilled Driven Gravel Other Is well site subject to flooding? ........................:........................ ............................... Yes No,,C Is well located in a realty subdivision? ...................................... ............................... Yes No -,K Name of subdivision Lot No. Water Well Contractor: Address-9'Y Is Public Water Supply available to site? ................................. .................:.......:..... Yes No 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 ^ o _ - -- 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 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. y revision or alteration of the approved plan requires a new permit. Well to be constructed by a wate ell drille certified by Putnam County. Date of Issue Permit Issuin Offiicial: Date of Expiratio Title: Permit is Non- Trannsff ra pc / White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 vs -25' 4- PUTNAM COUNTY DEPARTMENT OF HEALTH D_TVISr0N - F" EMRO! PI TAI7 =LTH "SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL.SYSTEM I FILE NO. Ownerge.AIOLSK CiY5'*,0,W'CA—_ Address Located at (Street �� STRgjs :r /2 Block y/ Lot zo � 2�1Z �Indicate cross street) Municipality jUfr,,s,,,, j %,e �y Watershed lVew SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Water Level No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches Q 110,'07 10f 13 20 23 2 2 /0,' /& �o: Z3 7 20 Z3 3 3 i0'2S is 32 7 zo 23 3 .. z 4 5 2 10;2.< 10. -31 00 Z 3 3 Z 3 10:31 10,'57 (0 00 Z 3 Z 4 5 � 1 .. 2 3 Notes: 1) Tegts to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. A11 data to be submitted for review. 2) Depth measurements to be made from top of hole. r , .",�, TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION .,DESCRIPTI9N.OF,S.QILa: °1 TdCOU IT, RED ° 1V .TEST,,. HOk F, DEPTH HOLE NO. HOLE NO. 2 HOLE NO. G.L. 7-0,,40 5 0 e- 6 i 12" t7 K 18" 2411 30" 361 42" 48" 5411 60" 66" 7211 78 f, 84" :....:::.:.. :.INDICATE �LEVEL-�.4T.�=CH- „GROTJ !..WATER -IS- YENCOUNT-ERED �.=- ...,,,.,,.:.... _....ti..:.: ,:: .,..,.:,;.:....:•:.. >:...:....: - - TIQDICA!'E- L�VI"L _TTO wHICH'VATER'-LEVEL RISES `AFTER -EYING ENCOUNTERED TESTS MADE BY Date /P7Z DESIGN Soil Rate Used Min/1 "Drop: S.D.. Usable Area Provided No. of Bedrooms Septic Tank Capacity /ZO p Gals. Type_ c, Absorption Area Provided By BOO L.F. x24." 3b” ✓ width trench. .� �% .,��►�4 per n 12 Name J�=Ph+ SuGL��i,g�v b.lgnature_ ��a' gggqvqqpe f� .y V o E sGgt� Addre s s G�ie,� Pc� SEAL /�.�s�a.e9s9c �/. ✓_ /OS4/ a $o a o p o o THIS SPACE FOR USE BY HEALTH DEPARTP2ENT ONLY: 2aagb,oi�t 0��geao Soil Rate Approved Sq. Ft /Cal. Checked by "'a��g�p��`'te M MT hh . J . . . . . . . . 000 Q Y 559 QQ P !,X Zj! SABA 'T QQ 77 Wk looks K00% 4A, no N�. VS . . . . . . . . ..... . . . . . . . �< r: . . . . . . . . . . . . . A Alto, Q, WON mWf %t Q" MT hh . 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C I \\ \ \1V 4.0 1 / / / riraq 23.08 ak 53 ! 1 \ \ ` / • +pq `� 20.10 AC. 34 a4 Y a 84.07 ° 63.54 AC alr,� 56 z x mzn y E / aC / ralAb = f -I "m 50 AC. L/ 60.26 AC. 84.11 1 Y I ml 9 I t I it Nsi ...49 is I I i },'• \�� vr�i 37• °"' ai 25.00 AC. I G I C - I i � 'I -0v d a'zx n.1a 1zh - 52 �1 3e 31,78 AC:..i : .. It R �, I ' IAL1lfR 10mM1A1D F8..•Pp 39 1/ 6.21 AC. >uau / u1.n ur.m I/ (y 50 .,•�: - 4i. r 1 7.47 AC. C, 39.65 AC. = 160 4 Ixa� 1 e I s I 9 yl,y O 1 31.01 AC. I. I 3 mi.a (J W. 1 unm x m `"x 1 rlaa 1 »a6.74 AC., uAa 1 aD+e 42 �IZU 20 •AC• 1 45 II I' X84. 19 ; a RECREATION AREA 22.69 AC. CAL. CO. 43 . 4.26 AC. I 9TER CO. `l 44 MI _I.Ii At _ i•� v3s _ :� •L07 LEGEND �. I � I •Lia000 I! I to ; .. +ci 72 73 74 'i PRELIMINARY :MAP Ie 91400 •.•.•••••• a[01.er0a LIL0 Am {1101 "xw i' .► an¢modln..® .• .{GALE 1; �1 KED O."10a IOV m • • .. .. ,�,,,m„m «;„ 83 85 ' TOWN OF PUTNAM VALLEY m to r--+ Ce101nm m AN 1; tam Q 100 i L 100 '101 m t.9 1 "M mmme .5 92 0 PUTNAM COUNTY. NEW YORK un s m!u' nmeolwl..._1.n.91 un lO mlmut I rues •rm l r n S11rz rta1[ [mpiurzf ue'.L1aa n w i %i j 3.1 ;0a I 41 4 48 20.85 AC. zlara .gyp• A I 8 89.00 AC. %i j 3.1 ;0a I U) V) 0 rj1 Z 0 (A _j --I CA -0 r- > aj 0m r1l ;0 01 ,j Ij CO -N co m m -pel 101. > A m ;u Sy 71 4 14" - m 4 -�s -0 p- ca m a M;u Ln C] S -0 0 co r— Q S02'57'5 -W --1 > --m 4 c) 57m, � 0 z I / 0Z I r N> * C) z of \ A Ij C3 0 i;c so qf � -.6 d1 e O 4 .4 CERTIFIED TO: ANTONIO RAIMOI THE JUDICIAL TI FIRST* AMERICAN MONEY CAPITAL ITS SUCESSORS MAP C LOT 1 1) MINC TOWN OF P1 I- IPREPARED BY: ROY - DYYARn T1 SURVEYING AND LAND 690 HORTONTOWN Rok HOPEWELL JUNCTION, I PHONE: 846-226-621. NrO� oz� m� ?D Z f— I ` I \ _j O- TC D ap mm cn v �OD 0 ` D a c) m Ln X Lid r d O D ca rnm to I LEA N v O� p 13 g3 LL 4 � mQ 0 f� �.�° " N v Gi S02'57'SS'W M m �' 57.80' t O Z OD> � z \ II \ 9 a 0 ` D a c) m Ln X Lid r d O Is CERTIFIED TO: ANTONIO RAIMOI THE JUDICIAL TI FIRST AMERICAN MONEY CAPITAL ITS SUCESSORS MAP C LOT 1 "MINC TOWN OF PU PREPARED BY: — y ROY EDW RD T] SURVEYING AND LAND 690 HORTONTOWN ROA HOPEWELL JUNCTION, 1 PHONE: 845 - 226 -621. D ca rnm to I LEA N v O� p 13 g3 LL 4 � mQ 0 f� �.�° " N v Gi S02'57'SS'W M m �' 57.80' t O Z OD> � z Is CERTIFIED TO: ANTONIO RAIMOI THE JUDICIAL TI FIRST AMERICAN MONEY CAPITAL ITS SUCESSORS MAP C LOT 1 "MINC TOWN OF PU PREPARED BY: — y ROY EDW RD T] SURVEYING AND LAND 690 HORTONTOWN ROA HOPEWELL JUNCTION, 1 PHONE: 845 - 226 -621.