HomeMy WebLinkAbout4699DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
91.25 -1 -16
BOX 35
76M
II
OR
OR
� �, 61114
r
r
'�6
6. .' i or
I.
' r
, '
OR
i
,'' I
III
I J,
roll �,
Nor
o.
6
l', ,..
AelpCi • o
17V6 I V `{ VVV V
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
x
please print or type PCHDP @rR1:Q�
Well Location
Street Address: TownNillage: T� x Map
1 S + U Rd. �.ake.
Map Block Lot(s)
Well Owner:
Name: /I
Address: 0 /,A
Phone #:
rK
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 gal.
Replace Existing Supply Test/Observation Additional Supply
Reason for Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
Y V1 elr s �0 Cod ees
c f edr eta o u*,( A ?•oov -va
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 Lot No.
Water Well Contractor: 0 e Address: A ar- y &� / 4 ate.
Is Public Water Supply available on site ? ............. ...... Yes _ No i =V.I /. j
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.
Qote �X� 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 Departmei
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 Commissioner of Health. Any revision or alteration of the approved plan requires a
new permit. Well to be constructed by a water well driller certified by Putnam 4unty. '
Date of Issue � Permit Is ing Official:
Date -of Expiration E--2z Title: N
Permit is Non - Transferable
Whi a copy - D file; Yellow copy - uildin Inspector; Pi k copy - Owner; Orange.copy - Well driller WP
�.� To 'D� �n i \ Form /0.6
'l�11 �V1,� � Rev. 3106
SBERLITA AMELER, MD, MS, FAAP
Commissioner of Health
1,0RETTA MOLI'NA
RJRN MSN
-Associate commissioner Health
ROBERT J. BONDI
County Executive
Director of Environmental Health
DEPARTMENT OF HEALTH
DRINKING AND RECREATIONAL WATER
Norman Anderson, Inc.
152 Barger Street
Putnam Valley, NY 10579
Re: Proposed Well Hamell
12 Sylvan Road
(T) Putnam Valley
June 3, 2010
Dear Mr. Anderson:
A field inspection was conducted on the above referenced lot by Mitchell Lee, Public
Health Technician. The application to drill a new well is approved with the following
stipulations:
1. The well is to be constructed with a minimum of 53 feet of casing.
2. A Well Completion Report (WC-97) shall be submitted no later than 30 days after
the well's completion by the permittee.
Please contact me at (845) 225-5186 ext. 46233 if you have any questions.
------- -- ---- .---Mitchel-l-.D-. Lee - -
Public Health Technician
cc
,-If Men -
110 OLD ROUTE 6, BUILDING 3 - CARMEL MY 10512
(845) 225-5186 FAX (845) 225-5418
- -r .° .:- .';.�.,e ..x'�G.' ♦: �':i..,..r•- _::ii:..� ..v, -,--.i o: ei'Y: -�wa:: _ "•:r ^�- �+!'+J .- _ ...�� +.w.:.e.t s��: :'•� . _•. _.,:: w. i,�.'� =. ^ + +. ...;•-:�� �M :..-.�'`
\i
J
G,
C/
oq
ce: Q6 caaanihe: eeSlrovalld-forli•.6 Map sadcopter
:ot only U said mip At coplte hear IM lmpreued
N V af she e>rivoper ashore ttuhmure appease kwon.'
c
c
fz' /` ✓yo
cURVEYSO a PURPARSD BY
= • t
F
It---,S All CAA
J
,•�
LAND SURVEYOR. P.C.
�+
:O WOODSURIGGR ROAD ROUTE t17
'1 N.5Gr•2.5rC� i.
%'
120.00"
HATONAH, NEW Y011H'IDUMS
A. r m r Ia.
s
•�
� °'
Q.
�
'
t`,
�
Wei
rY/P // UJ.e°
� I
a
tiJ
l
BR j e,
Bo
79
76 ! yr
u
1,
�
y
: �'
PO, 7d' :
I
• e
y
PAr °p
\Y
�
FieJ�61F�
f,
Q
xavrE �qre
�
o
viN
Ll
cool
c
c
i
cURVEYSO a PURPARSD BY
ALEXANDER BUNNEY
J
,•�
LAND SURVEYOR. P.C.
�+
:O WOODSURIGGR ROAD ROUTE t17
HATONAH, NEW Y011H'IDUMS
A. r m r Ia.
O
GL15\
�. sURV�Y 17,x- ��Op�,prr
'� PRRPA.QGa.O Fc,Q
es /ra.1/w S or
w romm ow Rvirmof vw& @ ep
• � PUTN�4�y1 COUii1%�''
NEW YORK
n
a � I•
.9 rho °o.
'sTNKE
' a
19-9
A I\ wo - wmx 1*l7,R 111y 9snak
_11.!1 1'rL9 WKIt CR crNWA ?,t/, f?
-7M%h'CH wr-.11 Tilk 121mit.q trAh
(1 r4M" Ttg"- LBHUB"WSr'r• 1 era• `VIf1a
AVATH f.^NL, Tt7L6 A£60L1A',P r. •.
AWAWI16S .rNOlVN Ae,090N BE/A°!o' GOr' 77
"w 84 mz-4 ds /YE• BGOCA- 66, .9l Ji/ONA.- On/
2-7 R JFi /O /NFrP F /CBO /N I-N e °°UJNFIii! C04.),V l y
4rAWA -V o/�14=0 ON./VWe ag °:929 A.! d /A ,-.V- .di $ -C. .
SURVEYE0AS IN POSSESSION FILZ No.Y- %ag -lu
r{
_ re:>:6ralmns htreM ue Yand•icr R'.e trip end ropuc
W Moy H am Insp al capita hest Ihs hepimed
of (he wtvprf whose dgtwufe apptus kcfren.7'
ex,ir, - /x� fsORYey 011c' PROPfpJ1'
RAYi MM7 4 ✓41.Z/4 GAIGLAG/,/��
1 Pt/d!P N W� { w TDIIvN of w AW Y L L �
> T 1l�1 +4 Y
: t o j _ Pvr/tWO cOVi 11rK
B/ Bo 79 76 77 (� NEJV YORK
c y .
y I'
If
�\�TT �l HOUIE OAR. `I `
� .. t ` al i k � ' -a+ � ' +.r -x 1�YF!EI] n' N +' %IY t*tY,R fOt•sfBON
' • � t Q � � � d CIIS•Y1.� 11YL8 1'.:ItGRlJi/;A IlNI•A!. Y, 1�
L`, V lD C v I!C sRSRl1iCR tVl':N 'dlk )71 N1)1(,tif ,frA„
AOu iria TnL TMLB guilt" hf� I�ti' Yllli
d:'A•flf f tX+. TrMR 1f4UUA', f• 1'. ••
) „� FOtJNO'1 % I
t y�o�e of 56•z¢'!V 140, CPO' sr,AYE
r
cSYL 1/AIV Rolgdo
f
Yp PRRd l /1�ES .sNO,yN /I.E.PWON W-IM LoT.r 7 7
' 6URVLYSO a PNEPARSO BY iPU 8?� /NCLUl/YE BLOCk 66, Al r//OWA,- OA/
ALEXANDER 9UNilEY /XAO ENTIlEL�d f .�fSk /L L, fECyYp�/
O J /M�90 F /Lt°� /NiN� PUJN.4/y! Co/JIVJ}�
'LAND $ORVGYOA. P.C. 'Xit'S F/ /D OfF /G� OA/ N B i9a9 .r'J hfAA.v� Jdi C.
r'v SO WOOD98RIDGU ROAD ROUTE If7 y
IfATONAN. NEW YORK' 10386
i
SURVEYED A6I IN POSBESS1oN FILE No. T - %3!
?i.
if r
%dk
•:G
j
` PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
I lnterna0 Use Only PERNN O
❑ Repair Permit issued in last 5 years Or Not in Watershed
❑ Repair within Boyd's Comers, W. Branch. or Croton Falls Res. Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION 1 S I� V��,,� TOWN
OWNER'S NAME 7 61 Ur PHONE # A/
MAILING ADDRESS 12- S' i.1 v q"— 120
APPLICANT 1. C
Name & Relationship (i.e., owner, to , contractor)
DATE 41130 12-010 FACILITY TYPE PCHD COMPLAINT # iU o
PROPOSED INSTALLER /� ,�/�/ ex-e-, �'� c PHONE #
ADDRESS 1,5 � . REGISTRATION /LICENSE # /Q / 7 e l �
Pro sal (include a separate sketch locating the house, prop@ft lines, all adjacent w 00s Within.
Vast oft repalr and the location o4 existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.
I, as owner,agree to the conditions stated on this form
SIGNATURE -- TITLE .-pagE . DATE j�j�1 ° g
.�h��pi:$PIi.r,:ti3e to cgrrrpiywit tha conditions of this permit fr:Qlis "s�Rr stn
SIGNATURE- /" TITLE .� DATE
QBnsOlert�
n conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate.ahoving:
a. Owner's name, Site Street Name, Town and Tau Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair vAll function.
5. No competed work is to be backfille�ntil authorization to do so has been obtained from the Department.
Proposal Approved �` Proposal Denied ❑
-"=. ,. ,T) QJ <:; I- �911xel
4 / O
Inspector's Signature & Title Dath Exp ation bete
Repair proposal is in compliance with applicable codes Yes O No CCU'
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2107
ARROW EXCAVATING, INC.
15 AVALON COURT
HOPEWELL JCT., NY 12533
(845) 297-4505.(914) 528-4395
JOB. FA (A 1'
SHEETNO. %-L V&-4j iZ %D OF PALL
CALCULATED BY 01/96&11-1 1EXC- —r.'C DATE t'l - 2�3 - Zel I Cl
DATE
PROOM204-i (Shale StM)205-lAdded)
MEMORY TRANSMISSION REPORT
'TIME .�,4 APR .-30r 0.10_. 02 -'A3PM
r Ie .....
TEL NUMBER 8452787921^
NAME ENVIRONMENTAL HEALTH
FILE NUMBER : 632
DATE : APR -30 02:01PM
TO . 82276436
DOCUMENT PAGES . 001
START TIME : APR -30 02:01PM
END TIME : APR -30 02:02PM
SENT PAGES . 001
STATUS : OK
FILE NUMBER 632 * ** SUCCESSFUL TX NOT ICE **
PUTNAMi CQ3UNTY Hf= AL_7rH DEPAKTPdiENT
MlWiS10N OP ENV'1FtONPV1ENTAL HEALTH SERVICES
mck arttmrnaa
Q raopatr Pett.en es3uaa en ens - s yearn No in W aterstted
Q Q Repair VrttfteR tiOYd'9 G- n.o.ts. W_ BranOlr OT CCett.f. Fal[s Res. Q ® ®legated
Q O gepalr whhen 200 R 4T a wreaer --Yr9a a OEGmappeA ra.etlar.A Q ,icint Meview
SI TE LOCATIOW TCiWN �v-ty 6Z
®WNEFi'S NAItAE i9 y s^ _ - - _ —r PHOME # &41A2-
MAiLIN431 ADDRESS -.2 i' /U!__ Q t2 b >� �i... -a-- -- t r -
APPLSCANT� Z:7-- ..-
�� Hearne IL Ratatie>.>:ihiP p.e -. ewrter. rsr.tra -tor)
DATE _ <��s �O ,[ U FACILITY TYPE s.'1 S PCHC COMPLAINT # RJ a
PROPOSEC aPISTAI_lER �% c�!/�/ ate-. aCC_� Z��y.. c PiiOME #
ti. 6sDCiRE'a�s; ^ /r+ .KSV/1% -�c�` 1�a��• �f. F�EGISTFd/9110P�Q/L1C:NSIEp Z4:5) /?
:..
Pr000sai pncatnda> a SepatmSte sltaitcat amcatLng tftef 1'110"00- prIOP09mty 05nas, =UU. taratUtan 200 ~
Nest 09 a- spent. and tote 94: l �on o¢ wdatinn asta9 (DMOP-s -a sy>aat®ttsD
NOTE: The Capartrtient may require submittal of proposal from licensed professional depending on Me
nature and e>ctent of the repair.
...r
1. as cwner.agree to tote conditions stated on mis form
:31C31VATURE ^—= TITLE t?•✓r7ER DATE ~i- �'"1� - 8 S'iT
Qaawrtea�
1, ttte septic installer, agree ti eom r ly the conditions of this permit for the septic system repair
SIC3NATUFY ..Lc i TITLE _ OATE_' %/ s /r`
Qlrtaaaa0ear'� '"
I —Procurement of any Town Permit. It oppltoabia.
8. Submission of as built repair sketch by this ;.optic system instmilar whin 30 days or tft,m repair. In 4up11c3ffia mftow bM:
a. C3wnse memo. Site Street Nana. Town srtd Tax IWSp number
b. L mti-n of installed components tied to two fixed p -ir.C9 -
c_ Systern doscrlption (e.g.. 1260 gal. Concr®ta septic tank. etc.)
d. irrstmlbarm• panto and phone number
3. Syatam repair to be performed in accordance with the above Proposal and conditions
T
4. he prop -sad SSTS repair is considered a best fit design and them Is no guarantee to the durafbon at which the
cornpletea SSTS repair W1il function.
S. No --"plated Work Is to 110 backHll 'ntii mutttoriration to do ao pas peon otMWneo Worn ate esaparay.ertc.
IIoPHRI au_ 183E 40ML.V
Proposal APProved Pr -p-sal Canied Q
Inspector's Signawre ak -T-mei-
Flwpair pro l Is in com linnom with a li -able cod%A6 Yag hIm
COPIES: PCFIO; Clwnar; Installer
PC -RP 99ML b=lew. 2107
e ` JOB�U
ARROW EXCAVATING, INC. SHEETNO. � ���� OF 6k.ffekskLC
15 AVALON COURT
HOPEWELL JCT., NY 12533 CALCULATED BY DATE
(845)..227 -4505 ,(91.4) 528- 4 395..
DATE
Anal F