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04773
- - - PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
i
NO�E: /Eact location of well with distances to at least two permanent lafidmafks to be provided on a separate sheet/plan.
9WxS' 1AAA0.,
Well Driller's Name Address: ��.
Signature: Date: l
S
/a 2
White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller
Form WC -97
X Wi ltige _ - _
T26C.Gric1 -#
Map Block Lot(s)
Well Owner:
am : Address:
Use of Well:
1- primary
2-secondary'
><Residential Publ' upply Air cond/heat pump Irrigati
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion Compressed air percussion Other (specify)
Well Type
Screened Open end casing -,<,_ Open hole in bedrock Other
Casing Details
Total length 40' ft.
Length below grade N �` �'ft.
Diameter in.
Weight per foot l6 lb /ft.
Materials: >L Steel — PI akic _ Other
Joints: _ Welded Threaded _ Other
Seal: :L4L_ Cement grout _ Bentonite Other
Drive shoe: ,> --Yes _ No
Liner: Yes � No7
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield Test
_ Bailed _Pumped 'I, -Compressed Air --
Hours-)/
Yield -5 gpm
Depth Data
Measure from land surface- static (specify ft)
During yield test(ft)
Depth of completed well, in feet
6
Well Log
If more detailed
information
descriptions or
sieve anal ses
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface.
a
'"
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type hti Capacity
Depth ja` ModelS: —
Voltage ,i4 o HP .
Tank Type1.XX- 2-!�d V o I u p e ,
Date Well Completed .
71; lo
Putnam County Certification No.
Date of Report
Well Driller (signature)
i
NO�E: /Eact location of well with distances to at least two permanent lafidmafks to be provided on a separate sheet/plan.
9WxS' 1AAA0.,
Well Driller's Name Address: ��.
Signature: Date: l
S
/a 2
White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller
Form WC -97
IPUTNAM COUNTY DEPARTMENT OF HEALTH
Ab SLO-t3 - a3
DIVISION OF ENVIRONMENTAL IHIEAIL'll'IH[ SERVRCES
AIPIPLIICATIQN TO ,CONSTRUCT UCT A WATER WELL
`please print or type
Well Locatiom.
Street Address: Town/Village Tax Grid #
�� SO 0) l [ap L�b Block Lot(s)
Well feu:
Name:
Address:
Use of Well:
Residential Public Supply Air /Cond/Heat Pump Irrigation
I- primma>ry
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought gpm # People -Served Est. of Daily Usage _gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
dDIrffl ng
New Supply (new dwelling) Deepen Existing Well
IlDetaaled Reason
,for IlDrr61ling
W \rAtiwN . ®' ° UAIII&I Ul W � 2 V '
Well Type
Drilled Driven Gra el Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? ...................................... ............................... Yes . No
Name of subdivision Lot N, o.
Water Well Contractor: �d ress: �j r
Is Public Water Supply available to site? ... .�2 ............... ............................... Ye. s, No
Name of Public Water Supply: Town/Village 0.
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
at ' sr.JAi�lricant Sign e:
11t
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
c � other
wise
ntamin,tesurface o o d ater p �or vJ A fwO�t,6v-k. esfa I � C)
�R PROVED GR C TION:
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 well driller certified by Putnam
County.
'Date of Issue �2 Permit Is ing Of ial:
Date of Expiration Title:
Permit is Non- 'I<'>raniffen°> ibRe
9 Vhite copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; range copy - Well driller
Form WP -97
I
BRUCE R. FOLEY
Public Health Director
Ot
.:rY.. -..iyy �.�.r0•...w�,a h..JyJ.. ei4:,,'Kx: }:v p.-��v. .. - _.....�A: ..=L. r.�., :�I
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
LORETTA MOLINARI R.N., M.S.N.
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/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
PUTNAM COUNTY DEPARTMENT OF HEALTH
SPECIFIC WAVIER
NAME: NX a Las Va6c
ADDRESS: 2 5oV1V�S0
SITE LOCATION: SCc1N1 e
DATE: `I
S�see+.C�. PeeUiII, NY 10537
STAFF PRESENT: Rob M., Mike B., UdW&., Shawn R., -Bill H., NOM
SPECIFIC WAVIER PvpoogeO weA l ;
REQUEST:
6-_e -r;
' SSTS
iV. ty- �. ,a, en �� -.. - ,-,... .T .... ��.. t . -r.X . .t :t•faf
DOES THE PROPOSED VARIANCE REQUEST POSE A HEALTH HAZARD OR
ENVIRONMENTAL CONTAMINATION PROBLEM?
DISCUSSION
REQUEST APPROVAL OR DENIED
APPROVED
0
DENIED
MASON FOR DENIAL
r
DATE:
DIRECTO 10
YES
NO
WILL DISAPPROVAL RESULT IN A SIGNIFICANT HARDSHIP?
YES
NO
DISCUSSION
REQUEST APPROVAL OR DENIED
APPROVED
0
DENIED
MASON FOR DENIAL
r
DATE:
DIRECTO 10
Sw -,r3 -5s
NEW YOR4: STATE,n6',�;�' ��tEf�%T 7F:kf!":Q�Tt;1 :: :. �.-.>3Cl$'IOII.Eval"
Bureau of Community Sanitation and Food Protection from Requirements of Part 75 and Appendix 75- A,10NYCRR
for Individual Household Sewage Treatment Systems
/ Last Name First M.t.
Name of. Applicant L GAS.
s
No. Street. City own State Lp -
Address
32 �nlnv�so� S�✓ee , Lti�e eel�Cs�C ►�� ,`( -= -- [03"7
Site Location
1. Reason why site does not meet 10NYCRR Appendix 75 -A (check appropriate box(es)):
;separation distance cannot be achieved.
Excessive slope.
High groundwater.
Inadequate depth to bedrock or impermeable layer.
Soil unsuitable.
[]Other (explain) .................................•..................................................... ...............................
2. Proposed design or conditions of waiver:
...................... ............................... .
o....o . ....�✓. 1......�......:.... e.... v�. .....o..�. ... 5
av�
:...5ti...•.`t :.�= . ..>�r. ,� n T5
k. :.�.Vkee ............. : . .... :....... ':....
•
C.e� ?
.. .. +. i. 1.u..�!!1.. ~.c� ....: . Q..+ .e� ..... o .....c . w�.. ..� ..... ! .�.v . ........... ..... ................:..............
3. The proposed design may have the following limitations (check appropriate box(es)):
J Increased risk of well or spring contamination.
Increased risk of surface water contamination.
Expected design life of the system will be diminished.
Operation of sewage system is subject to mechanical problems.
Other (explain) .................
Additional information attached
Construction pursuant to'this waiver request should not pose any foreseeable health or environmental problems. In accordance with
New York State Department of Health Administrative Rules and Regulations, Part .75.6 (b), a waiver is hereby granted. This waiver
may be revoked by the issuing official for a change in conditions for which this waiver was granted.
ORIGINAL - Local Health Agency
COPY - Applicant/Design Professional
PART. (l- .NVIRONM ,N
%r ;r.L K°> SEnf .Y e - •i`". . 'f-y s %./ D�pR Jpn
�r�t..lyw . ...f A"^.�R, TAR '..• _�, .... ...� .
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes. coordinate the review process and use the FULL EAF.
C] Yes 19 No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 • It No, a negative declaration
may be superseded by another involved agency.
Yes tpl No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible)
C1. Existing air quality. surface or groundwater quality. or 'quantity, noise levels. existing traffic patterns, solid waste prodLction or disposal, .
polelntial for erosion, drainage or flooding.problemsl Explain briefly: -
V
C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources: or community or neighborhood character? Explain briefly:
No
C3. Vegetation or fauna, fish, shellfish or wildlife species,. significant habitats, or threatened or endangered species? Explain briefly:
No
C4. A community's existing plans or goals as officially adopted, or a change in use or ;intensity of use of land or other natural resources? Explain briefly.
No
C5. Growth, subsequent cavelopment, or related activities likely to be induced by tre proposed action? Explain briefly.
o
Lo. Long term, short term. cumulative, or other effects not identified in C1-05? Explain briefly.
C7. Other impacts (Inclucing changes in use of either quantity or type of energy)? Explain briefly.
.acs ...rl V � • r o . w+ha s :... a+v.G* •.� .' ; �; ._ r+ , .. .a . ..... ._. -., r..j...1,- _..tea .w Y'�^ --.�_ _.+A � .. n _......' _ - . .-. w ter.+ !R ..._,yam .... . q �....
D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
LJYes ZNo It Yes, explain briefly
PART 111 — DETERMINATION OF SIGNIFICANCE (fo be completed by Agency)
INSTRUCTIONS: For each adverse effect identifled above, determine whether it is substantial, large, important or otherwise significant.
Each effect should be assessed in connection with Its (a) setting'(1.9: urban or *rural); (b) probability of occurring; (c) duration; (d)
Ireversibility; (e) geographic scope; and (1) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed.
❑ Check this bbx if you have identified one or more potentially large or significant adverse impacts which MAY
occur. Thed proceed directly to the FULL EAF and /or prepare a positive declaration,
F4 Check this box if you have determined, based on the information and analysis above and any supporting
documentation; that the proposed action WILL NOT result in any significant adverse environmental lmpants
AND provide on attachments as necessary, the teasons supporting.this determination:
f.
1l D L• � � Q l IE£�Z OAF +LNG n+�4.ti 1✓L� '
or T %%pe Name t a risible Officer /in Lead Agency Title of Responsible Officer
ignature of Freparef(If different from responsible erlicer
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02/96 `. Title,
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FOR ASSESSMENT PURPOSES OIILY, '.REVISIONS I SPECIAL DISTRICT INFORMATION
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Certifications Indicated hereor
existing code of practice for L
Professional Land Surveyors.
the durvey was prepared, anc
agegcy and %or lending instit
Institution, for mortgage put
Cerificatlons are not translen
Only opies from the original
thit(,Land Surveyor's inked or
cop tIn addition, unauthorized alto
Surveyor's Seal Is a violatio
Education Law.
The,location of unaerg►ound I
certified.
Certified to:
�7
Field survey performed: Oct
il
and�pap prepared: Octobe
i4
a.,
David L. Odell, P.Lf
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Certifications Indicated hereor
existing code of practice for L
Professional Land Surveyors.
the durvey was prepared, anc
agegcy and %or lending instit
Institution, for mortgage put
Cerificatlons are not translen
Only opies from the original
thit(,Land Surveyor's inked or
cop tIn addition, unauthorized alto
Surveyor's Seal Is a violatio
Education Law.
The,location of unaerg►ound I
certified.
Certified to:
�7
Field survey performed: Oct
il
and�pap prepared: Octobe
i4
a.,
David L. Odell, P.Lf
�r
th..
ra
v,i SL
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E f
=�F
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# PUTNAM COUNTY DEPARTMENT OF HEALTH
dDIIVF3gOftT OF ENYdIIiORTMIEIY'ICA1L IfIIEA1L'Il'H SE&8WCES
AP.IE LIiCATIONTO CONSTRUCT A WATER WELL,. .
please print or type PCID Permlt #
Well ]Location:
Street Address: TownNillage Tax Grid #
Mhnsons*- I L Map Block Lot(s)
, -
Well Owner:
Name:
Address : 7Afd. rm- p 5E it Lis //. y 11-37S
biL KoRiK
3z 3 �k .1 -
n
�L
f,50 .
Use of Well:
Residential Public Supply _ Air /Cond/Heat Pump firigation.
I- p>ri>mnairy •
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought __,5 gpm # People Served __L— Est. of Daily Usage JQ CLga I .
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
1 ow
o k-awe- iF Fn . 5
e ejar -6 r-'--d
for ){Drilling
Well Type
Drilled Driven 01ravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? .... ::................................ ............................... Yes No
Name of subdivision �, �'1 `�e�1� <�K �1 Lot No.
Water Well Contractor: T- Address:
Is Public Water Supply available to site? .......... .................. ..........:..................,�Ye�s No
Name of Public Water Supply: L!( ��� � y��a�v n,n�,�, L . To illage t
Distance to property from nearest water main:, M-. r
Proposed well location & sources of contaminate to be provided on separate sheet/plan.
Date: A1�cant 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 (3 0) 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 ' IFOR CONSTRUCTION: This approval expires two years from the date issued unless
construction o 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 well driller certified by Putnam
County.
Date of Issue
Date of Expiration
Permit is Non-Transferrable
Permit Issuing Official:
Title:
White copy - HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller
Form WP -97
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BRUCE R. FOLEY
FuNic'mP'cali4'L�iF«s::iF• t _.
LORE.TTA MOLINARI R.N., M.S.N.- ._.._
y .. .
S4s3ocfate ' �ulilic "'Fle ilYh director
Director of Patient Services
DEPARTMENT OF HEALTH
H
1 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 (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648
January 24, 2001
Emil Kotlik
32 Johnson Street
Lake Peekskill, New York 10537
Re: Proposed Construction Permit for Well #60 -00
32 Johnson Street, TM# 91.26 -1 -85
Town of Putnam Valley
Dear Mr. Kotlik:
Review of application dated August 27, 2000 and other materials relative to a construction
permit for the above captioned property has been completed by the Department.
This application has been discussed at this Department's January 10, 2001 "Specific Waiver"
meeting.
Based upon such review, and pursuant to the provisions of Putnam County Health Department
Bulletin ST -1.9, you are hereby advised that the proposed. method providing N ..aXpr supply is
"` oris derea'inadequate s "set iorth�eiow "lliere ore, approvarol this appTicafion. cannot )e
granted as stated below.
The proposed location of the well does not meet current Putnam County Health Department and
New York State Department of Health requirements for a 100 feet minimum separation distance
from a well to separate sewage treatment systems (SSTS).
The submitted application proposes the well 82.5' from an existing SSTS which is
unapprovable.
A waiver of the minimum well to SSTS separation distance for the proposed permit is hereby
denied by this Department.
Very truly yours,
Adam B. Stiebeling
ABS:cj Assistant Public Health Engineer
PUTNAM COUNTY HEALTH DEPARTMENT U ..16 N + M
1 Geneva Road
Brewster, New York 10509
JAN
26'0 7 0 .3 4 E
Ap
BMETER
Y 7.211376 U.S. POSTAGE
Emil Kotlik
�1
:�UaT.' �•�a a ... ab': '�C4c.. ..r L -R _ �'... � ,'1 v .�� ,... _ .�. . �.., w .ra4k:'.w . ♦a r i y� :.4 � u .c �,� ".� � .p. .�4
25
FORMAT CONSTRUCTION (PERMIT
NEIGHBOR NOTIFICATION LETTER
Date
RE Department of Health Review of Proposed
Sewage Treatment System for Property.
Name: Y�1 r�'��i �ILt�G ��b5
Address: 3Q pl-tftzo ! 5t- r7 4.
Town:_ !'. • PC_eK5K1
Tax Map r: jj -fib �;5 Fore, HAS,
S,
�l• �'. 11315
Dear M12,°I- RA -
Please be advised that an application for a Construction Permit relative to the construction of a
sewage system- and!®r.v_�ell- proposed_for the captioned-prgper.t i-haS,be�n.,u.i4de Yo the Piitt;arii.C.ii nxy_a: '-.µms._
f Department of Health. 'Attached please find a copy of the latest site plan.
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,
By. -> c
Title:i% -r Received BY:
By:
Address:
Tax Map #:
August, 1999
AppndxE
25
APPENDIIN E
FORMAT CONSTRUCTION PERMIT
NEIGHBOR NOTIFICATION LETTER
Date
RE: Department of Health Review of Proposed
Sewage Treatment System for Property
Name: F M i L !{� t� i K (�10.tL t.�lC l bZc ss =
Address: 3Q TOt4 czCIN J /02-42 r1c—MN 4-
Town:1..1� • PL =-�5K� I1
Tax. %Iap H i l�
� N• y. 113 �i5
Dear (�. * l PA . jocca,
Please be advised that an application for a Construction Permit relative to the construction of a
:sewage system and/pr. well,pr9posed.for the captioned property! has been made to the P:utnaria �`r`aunt :'; -
1� VOffiedt' of Health -' Attached please find a copy of the latest site plant/
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,
By:
Title:
Received By:
Address: ,[� �'2cl�e �t� ����Cn, Rs (�i � /L9 _(-3
Tax Map 9: 9i. � L - A
August, 1999
AppndxE
25
APPENTM E
FORMAT CONSTRUCTION PERMIT
NEIGHBOR NOTIFICATION LETTER
Date
RE- Department of Health Review of Proposed
Sewaae Treatment System for Property
MCLILRq- Wbt� CE S-55,
Name: F, rn I KAL* 7, -1
Address: 3Q 'Tow,&-w 5� 0+.ih
Town - U. • PL7L=K5K�11
Tax Nla p V5 H i Lts/
Dear p)e.ct-ma. 4" I 1315
,Vv .
Please be advised that an application for a Construction Permit relative to the construction of a
...sew age ystern and/or well proposedfor the captioned p apeay h j b o e i e o the. fa m.0 o u-n" t y
be ar,men_t o,f_Health. Attached please find a copy of the latest site plan.
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,
By:
ci L
Title:
Received By: lj& l V P
Address: A5 N_'111JAJ
Tax Map 9: _212,2 -C-3 -
August, 1999
AppndxE
_ - � __ , �Y:... --- ... ... .... ,sup• .. .:- ._, ... 7 _ .� � �. i .�., 25
APPENTUX E
FORMAT CONSTRUCTION PER`JIT
NEIGHBOR NOTIFICATION LETTER
Date
RE: Department of Health Review of Proposed
Sewage Treatment System for Property
\tame: �' IY1i L rl � K rl� c tLikcg iIL 'bb S5 =
Address.- 3Q SOH r,&-� 5 j - y 2 rj .4-1. t'
Town- U< • PL:;L 5K� I I F-bres� It
Tax. Nlap X11 -a l; ' ?S
A1• y. 1/3'15
Dear
Please be advised that an application for a Construction Permit relative to the construction of a
sew�.6ge system an or.well- proposed for.the captioned. property- has_been made .to_' e_Putnam CountX�:.
�'Depa rnei hf of Health._ Attached please find'a copy of the latest site plan.
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 - 613.0.
Very truly yours,
.Y.
Title:
Received B
Address: -2 � 1-3,,L _
Tax Map 9: 2a -8 - / -a
August, 1999
AppndxE
ell
25
APPENM E
FORMAT CONSTRUCTION PERMIT
NEIGHBOR NOTIFICATION LETTER
Date
RE: Department of Health Review of Proposed
Sewa;e Treatment System for Property
�� K �1'�alL« 1 �Dc' sS
Name: c . rn � l Kd 1 -1
Address: 3o 10�4r,5M 9 rjc�+ -h �.
Town: !.1(• f'� =tSK�
Tax Nlap r: �1 J -a L - V5 Fixest H i Lls,
�•y� lJ37�
Dear m CCL)a&,
Please be advised that an application for a Construction Permit relative to the construction of a
. atcUhy -o hseaa� system and/ y :a l a xdP to he Pui
Department of Health. Attached please find a copy of the latest site plan.
If you have any questions, concerns or information «,hich may bear on the Health Department's
review of this application, you may call the Health Department at (914) 278 -6130.
Very truly yours,
By: ,
(, Title:
Received By:
Address: -� k
Tax Map g: 99. ` a — I—
August, 1999
AppndxE
r
Public Health Director—
DEPARTMENT OF HEALTH
1, Geneva Road
Brewster, New York 10509
LORETTA : OLM Asti KN., 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
PUTNAM COUNTY DEPARTMENT OF HEALTH
SPECIFIC WAVIER
NAME: ��� dT<<tC—
ADDRESS:
SITE LOCATION:
DATE:
STAFF PRESENT:
_7F. L 14 - pri
SPECIFIC WAVIER
y ( y
REQUEST: ..... R
�S...... _ . ."t
DOES THE PROPOSED VARIANCE REQUEST POSE 'A HEALTH HAZARD OR
,ENVIRONMENTAL CONTAMINATION PROBLEM?
MKI
APPROVED
REASON EM DENIAL
c
DIRECTOR OF PUBLIC HPALTH
ZDEIED
YES
NO
WILL DISAPPROVAL RESULT IN A SIGNIFICANT HARDSHIP?
YES
DISCUSSION
NO
MKI
APPROVED
REASON EM DENIAL
c
DIRECTOR OF PUBLIC HPALTH
ZDEIED
BRUCE R. FOLEY
Public F.ealth, 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)278-6648
WIC (914) 278 - 6678 Fax (914) 278 - 6085
PUTNAM COUNTY DEPARTMENT OF HEALTH
SPECIFIC WAVIER
�.Py
NAME: wl o T L- t te—
3 2 �o 1-k-,, t4 L t4 _ pri k ADDRESS ��' �-
SITE LOCATION: "
DATE:
IBM
STAFF PRESENT: Bruce F.. Rob M.. mike B.. Adam S.- Gene R.. Shawn R..
SPECIFIC WAVIER (( C
REQUEST:
R. DOES.' 1HE "PROPO9 ED ° VAFuANCE -REQUEST POSE A�HEALTH� HAZARD ; OR
ENVIRONMENTAL CONTAMINATION PROBLEM?
-- -- - -YES NO
WILL DISAPPROVAL RESULT IN A SIGNIFICANT- HARDSHIP?
YES NO
DISCUSSION
APPROVED DENIED
RUEAS ON FOR DENIAL
DIRECTOR OF PUBLIC HEALTH
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