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Home My WebLink About0116DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.20 -1 -44 BOX 2 r ' , f' i �. . IN! L I, ` `I 1 L , ti NN 00116 � I .� –�� PUTNAM COUNTY DEPARTMENT OF HEALTH L �� DIVISION OF ENVIRONMENTAL HEALTH SERVICES u5 Ps M 6 15 l 4ov2 .q.' APPLICATION TO CONSTRUCT A WATER WELL please print or type P0Der(1�� xy �e Well Location Street Address: Town/Village: Tax Map # D �; ✓ S � ct �Q Map Block Lot(s) Well Owner: Name: Address:/ Phone #: Use of Well: 1-,6esidential ;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 for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ....................................................... ............................... Yes _ No_J,-- Is well located in a realty subdivision? .......................................... ............................... Yes — No Name of subdivision Lot No. r_ . Water Well Contracltor:Al J le4 n 5�cpy trjj� Address: t o rr 7 Is Public Water Supply available on 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: Applicant Sig nature:a0 - fi4,idle, 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 Departmel 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 tie constructed by a water well driller certified by Putnam County. Date of Issue 3 CL Permit Issui 12c_ Date-of Expiration t Z1Q� Title: l Permit is Non- Traniferabl White copy - HD file; Yellow copy Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT # )q W 2 —I)_ • Well Location: Street Address: TownNillage Tax Grid ' -glow t L /1% Map i FMS t(s) Well Owner: Name: Address: r Well Type: Drilled Driven Dug ✓ Gravel Other , Depth Data: Well Depth a ft Static Water Level r ft Date Measured _,3 / i.... Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned I- primary Business Farm Test /Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Contractor: Name: Address: p �� C7 E+ �r (J �i a 114 v'! %�. �t Reason For d i W , cN h ` (� vii s e - l+! u A's Co r y Abandonment: Description of Work To Be Performed: 4� r� C'th,� 0 e� C (r i�v C 1 d Date: A pp licant Signature: PERMIT 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 been completed. b- Date Issue White copy: HD file; Yellow copy - Bull Form WA -97 REBECCA WITTENBERG, RN, BSN . Public Health Director ROBERT MORRL'S, PE Director of Environmental Health Norman Anderson, Inc. 152 Barger Street, Putnam Valley, NY 10579 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 845- 808 -1390 Subject: Proposed Well Maldonado 10 First St. (T) Patterson March 27, 2012 Dear Mr. Anderson: MARYELLEN ODELL County Executive A field inspection was conducted on the above referenced lot by Vincent Perrin, Public Health Technician. The application to drill a new well is approved with the following stipulations: 1. The well pump and any electrical components are to be removed from the existing well during abandonment. 2. The well is to be constructed with a minimum of 55 feet of casing. 3. A Well Completion Report (WC -97) shall be submitted no later than 30 days after the well completion by the perrnittee. Please contact me at (845) 808 -1390 ext.43131 if you have any questions. Sincerely, Vincent Perrin Public Health Technician cc: VP, file U) LO LO U) LO 615 0 143 FIRST C ` &C -, - 6,5per 71.64 43 cD 44= A 49.5 STREET co 95.50 00, 50 Lo 66 CIO 0 ® M N Q e-.l A 67 �- M ® M 65 S zio< 115 41 N rl Ri J 134.4.2 31.58 ® cn co cn c> v' 0 35.6' 30.38 N ,a SIT CA -n cn --I cn m m --i ? J w .p Ul 95(S) C31 CA) a� 34.70 Y 55(S) Lae. f 0 �. 10 4r S,� . . . . ...... Ki 4i 'FLO, tit .2:ow GI Id LL RAM uo� W, :o Li :5 RVEY 'PROPERTY WILLIAM M-9. ROSSIiE JR. RA. .H-- ..:FR0,551 rES�