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HomeMy WebLinkAbout0414DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -3 -68 BOX 5 00223 I rm I I I I !I me '� ;1 ,,� qq16 , ' ' r 00223 1- i, .' .��, ----•� fir- ��[r_ -_ - PUTNAM COUNTY DEPARTMENT OF HEALTH �, Division oilbsvlroomentil $ eslHtServlcae; Carmel, N.Y 1051 Most Provide P CONSTRUCTION COMAPLIANCE FOR SEWAGE DISPOSAL, SYSTEM ,OF Tow map Vjn. Located at ; � Map�j3lacjk�_Let. a Omer/ t Name �D:� H SerV7 d 2Y' Formerly �e �0 Sbbdivlsbn`Nsme appligan MaWnE Address G "j3 i - r�1V2 4�1 ' o P . y1 i , Subd.V Lot 1 Fee: Enclosed'. {'Amouri moo, 6G� Date Permit Issued 9' Separate Spi,, .Se Syetom ballt -by . n i* 1 e " I o n SzY uG Ci a ri' ' ,AAddreba I - s : p as Conaleting of ' �Z Dd ? Glillon Septic Tank 14J )e :`WI D, L of Q►-a s W/ �o J, i. _ �'�ot} GQ�,Pu►�,n P �L1 M�tfsl+.`PPu�,e cf few�rol 8r2''� D�sc4,a►�ai.- 'Pi'ae Water Supply= From Addee Pd I a� �er`"t ��t1a' �Sot� q� ��� on X Private SaPpIY Drilled byddsesa (� , Po'�iersa r, j Ill Y Rea J B 1y '(moo, +r p Lot Size�r— �1'cp(�j��� 14' Erosion "('nntrnl -Rppn .rnmplarPd'?, S ICeac,ired• Number of 19edsooma i 1" G i, Y Hue Garbage Grinder Been InetblledY N� "n other Regaieemente Da s 1 n q F.I u �► „� ff 8i A 1 g r w, I certify that ' the syetes(s lasted- serving the above presises ware constructed essentially. as ehown'on thd, plane ot.tha completed suck (copies of.which are,attachedj, end in aeccarrd& ce with'the standards iules and' - regulations in accordance with ilia filed plan, and the permit issued by the Putnaa County'.D n Data C(S��a „ 97A"Td'd rett '• ' . • n Ce►tifiedby • "R E. -AAb . Q 1 r I W J 2 -98 :09 License No. 29 210 Any, parson occupying premises' ferved Dy the above syste i6i shill promptly takd such action as may be rte *scary to eaciere the correction of any unsanitary conditions issuning' from such usage. .Approval of the' separite",awaapi system-iliall Oecoene pull and Vold si soon as "a pubt;: unitary ewer becomes available and the approval of tM private "water. suPDly, shall become null ens voW when r. pubik watw supply baCOmee evatilable. Such approval$ pre subject to rr diflriation or chigoe when, in tM "juegmerat of •ttw COrnm' l saner of ;MNI� suM oeatbn..niodNkitfloh M eMnoe le neeeal /y. gate � i �• ` � . " _ � Itw � /�.'�� 3/89 {;=� • Sep. 1 '94 8:05 N. AMER I CAN LABS NORTH AMERICAN LABORATORIES, INC. TEL 1- 914 -278 -7754 MEET TO: i% // edges FAX NO: a? xf- DATE : �_/ - f f TIME: 9 r NUMBER OF PAGES: (including cover sheet) FROM: LABORATORY FAX NUMBER: 914 - 278 --7754 If you do not receive the stated number of pages, or if you have any questions about this trans- mission, please Call 914- 278 -7600° F. 1 j Sep. 1 1.9.4 8:06 N. RIMER I CAN LABS TEL 1 -914- 278 -7754 _ _ P. _ - -- - WNORTH AMERICAN LABORATONIES,INC. ANALYSIS DATA SHEET TYPE: PW LOCATION: Rt. 311, Patterson, NY REPORT TO: John Servider ADDRESS: Rt, 311 CITY, STATE, Sip: Patterson, NY 12563 DATE COLLECTED: 08 -30 -94 TIME COLLECTED: 2:00 PM COLLECTED BY: Jim G:xe.ltieri REPORT DATE: 09 -01 -94 LAB # 94 -6163 SAMPLE SOURCE: Kitchen tap DATE .ANALYS;IS RESULT UNITS METHOD ANALYZED "Coital Colifor►n Absent COLILERT 08-10-94 THIS .�AM.Pl.,E! AS RECEIVED AT THIS LABORATORY �SF.T THE, REOUJR.ENIENT5 OF NEW YORK STATE DRINKINGWATER 7ANAARUS. Laboratory Director NEW YORK STATE SLAP CERTIFICATION NUMBER: 11218 SEP -01 -1994 09:30 FROM AUERSAHO' S PR i P1A P I E ^A TO HEALTH P, AVERI S A N,, 1 0"" S , re' -, %V i m A I lei A Tel. 279 -4909 PIZZA SLICE Regular ......... $1.40 Sicilian ..........1.50 Pan ........., ..1.75 White ........2,00 Broccoli .... , ..... 2.00 Extra Item 50c Route 312 & Brewster Rd. Brewster, NY 10509 FREE LUNCH DELIVERY $10 minimum per delivery PIZZA PIES Small ........... $8.25 Large ............9.25 Sicilain .........10,50 Pan ......... ...9.50 Extra Items Sm $1.50 —Lg $2.00 CALZONES Cheese ......... $3.00 Ham & Cheese ...3.50 Broccoli .......... 3.50 Meat & Cheese ...3.50 Chicken Parm Ro114.00 Pepperoni Roll ...3.50 Stromboli Roll ....4.00 .4.00 Extra Items or Sauce 50c HOT LUNCH SPECIALS HOT WEDGES Baked Ziti wlmeatballs ... $3.50 Spaghetti wlmeatballs .....3.50 Stuffed Shells ............3.95 Raviolis ..................3.95 Lasagna ..................3.95 Eggplant Parm Dish .......3.95 Chicken Parm Dish ....... 4.50 *All Dishes Served wrBread & Butter T Meatball ................$4.00 Sausage ..................4.00 Sausage & Peppers .. , ....4.25 Chicken Cutlet . , . , ......4.25 Veal Cutlet . . .. ........ . .5,00 Eggplant ................. .4.00 Peppers & Eggs .......... *Parm 50C Extra Fax 279 -8036 SALADS Tossed .......... $2./5 Chefs ........ , , .3.50 Antipasto ........3.50 Tossed wil Chicken Cutlet .3.50 Tosse COLD WEDGES Ham ............ . ....... $3.50 Ham & Cheese ......... , .3.50 Turkey ....... .........,3.75 Salami & Provolone .......3.75 Italian Combo ............4.00 Chicken Cutlet ... , ...... , , 4.00 wllettuce & tomato COGS i a ' WELL COMPLETION REPORT Office Use Only * * DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH STREET AOURESS. wNivl TAX GRID NUMBER: WELL LOCATION fiw e 3o Pte. 1 6 13L.-3-68 WELL OWNER NAME:' ADDRESS: 38'� PRIVATE X63 -101 Surrs�tfzus�i PUBLIC r , USE OF WELL KRESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND. /HEAT PUMP O ABANDONED 1 - primary O BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify) 2 - secondary O INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY O MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED EST. OF DAILY USAGE gal. REASON FOR []REPLACE EXISTING SUPPLY ®TEST /OBSERVATION ❑ADDITIONAL SUPPLY DRILLING ffNEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft. I STATIC WATER LEVEL _035 tt. DATE MEASURED U DRILLING O ROTARY XCOMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT ❑ WELL POINT O CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE O SCREENED ❑ OPEN END CASING OPEN HOLE IN REDROCK ❑ OTHER I TOTAL LENGTH _ fit. Of MATERIALS: STEEL 9 PLASTIC ❑ OTHER CASING LENGTH BELOW GRADE 60 _ ft. JOINTS: O WELDED THREADED ❑ THEIR DETAILS DIAMETER in. SEAL: ❑ CEMENT GROUT O BENTONITE ATHER WEIGHT PER FOOT 17 lb. /ft. I DRIVE SHOE YES O NO I LINER: G YES NO DIAMETER (in) 'SLOT SIZE LENGTH (It) DEPT TU SCREEN (It) DEVELOPED? SCREEN DETAILS PS RST ES ONO ONO' OURS GRAVEL PACK 0\YEV GRAVEL DIAMETER TOP BOTTO ❑ SIZE: OF PACK in. DEPTH ft. OEM R. WELL YIELD TEST r If detailed pumping 'WELL LOG it more detailed formation descriptions or sieve analyses are available, please attach. M fH00: ❑ PUMPED 1 tests were done is in- DEPTH FROM Water Well COMPRESSED AIR ! ; ` ormation attached? i ❑ YES 0 NO suaFace gear- ino Dia' FORMATION DESCRIPTION coot? ❑ BAILED ❑ OTHER It It In WELL DEPTH DURATION DRAWOOWN YIELD Surface It. hr. min. ft. gpm. WATER CLEAR TEMP., f1°F•1 QUALITY ❑ CLOUDY HARDNESS 1 ❑ COLORED ANALYZED? WES ONO ANALYSIS ATTACHED? 0 YES ONO STORAGE TANK : TYPE X-L-Ml —t oje.l 2Z PUMP INFO MATIOt! CAPACITY i;J '� 4J- GAL. TYPE CAPACITY "'t�RTNM EHYATT &SONS, INC: oATE�S T MAKER crztnal'44.0s DEPTH _3w, ADDRESS Well Drilling SIGNATURE''" •. MooEL S0 '1 VOLTAGE 13-0 HP - Box 171A €11 KNEW IRte. YORK 12563 _�i 31 PLn NAM COMM DEPARiMENr OF IIEALTH DIVISION OF ENVIROIZ=AL HEALTH SERVICES jo 4n A, Sewider 13, Owner or Purchaser of Building SestieA Tax MdP Block Lot Building Constructed by N,X,S. Roic6e 3f 9 - -- -- Location - Spree Municipality C e_oi a r - Fr-, f, Building Type Subdivision Name . Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the. sewage disposel 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 bepartment of Health, and hereby guarantee to the owner, his successors, 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 approval of the "Certificate of Construction Compliance" for the sewage disposal system, or any repairs trade by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. IThe undersigned further agrees to accept as conclusive the determination of the Director ' of .the Division of Environmental Health Services of the. Putiiann County Department of Health as to whether or not the failure of a system t:n caused by the willful or negligent act of the occupant of the the system... Dated this day of 19 4 Sjgnature Title (Owner) — Signature Corporation Name (if Corp.) .Address rev. 9/85 Corporation Name (if Corp.) PA&ess PUTNAM COUNTY HEALTH DEPAR YO DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D! Deputy Commissioner of Health. - FIELD ACTIVITY REPORT - NAME ADDRESS Cr No_ street Umn TM No. ��4MING ADDRESS P.O. Box Post Office Zip Code. TELEPHONE PERSON IN CHARGE OR INTERVIEWED Name and Title DATE TYPE FACILITY TIME ARRIVED TIME LEFT Sheet of Orig. Routine Orig., -,C-x nplain Orig. Request Compliance Complaint Comp _ Final Group Illness Construction Reinspection Field, Sampling Only Field Conference Other INSPECTOR: TELEPHONE: Signature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: PUTNAM CQUM DEPARfI OF HEALTH DI�Yew dB,.rataaldd Hs1iM6 Sat +loess. Caateai. Ii.Y. lOSI? � 1d PlsiwWe laiaat aBCEMPICA COBRUANCE FOR =WAGE DEPOM S= St T Pd+Ce.ir fc f) Twin, '.a r V"W i IBM" c.:ea- Iet 0 Tax bTapJ_ Bloei �. J W Name ..�o n h ,5>i"V 1 ca asww l -0'' Sa.1.1ee p 5Ts ®; Z�1 • Daoe et Ptevlooa, Appeowl - .inn A.nnrnvaA. - - FAAFT1ClnRAA Hd ft TM �Vm rw Los A Sectlaa Dad vola=B Nalober d B 4 9C£ Dealt Plow G P D PCHD N61ldcatlm Is Retisikod WhmFS li enwieted Se We" SetrerP. Syrleng a Comm d-"6 -GaUn Sepi T.ok aoa j x 2 'ti U/; 461(j), To be aeriileBe/ed by Address Wafer SWp4: Plmda Sttppb Frastt— e 1 _ . . set_ _Pa..ee SWpb D-RMW I, represent that 1 am wholly and completely responsible for the de"n and location of the proposed systein(s); 1) that the sepirate serer disposal •stem above oesc! Wd. will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a regu ions o nam County Department ' of Maeith, and that on tom pletion.th riot a'- Certificate of Construction. Compliance" Ytisfactwy to the Commiselofla► of Healthwill bar submitted to the Deportment, and a written guarantee will be furnished the owner, his successors, heirs w esteems by the OuikW. that 'laid builder will Diem in good :operating condition any pert of said saws' disposal system during the par ked of two (2) yews Immediately followlfeg thi"te of the imw anon of the approval of the .Certificate of Constructioiom Compliance, of the original system or any repirs thereto; 2),that the drilled well'daor:bod above will be located es shows en the approre0 plan and that old well will be Instal in accordance with I Lhe standards, 'rules and repo ate% of the Putnam County Department of Health. Data , Signed U, P.E. R.A. - Address 9i' clef ie.nse Nd ��`�"o APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the building has been undertaken and is revocable for cause or may be,amended or modified when Considered necessary by he Commissioner of Health. Any change or alteretien of Construction V. must a eve permit. �pptoved'to disposal. of domestic sanitary gstiege a_ private water supply only. Bob By Title 10/88 - V JOHN H. PRENTISS, P.E. CONSULTING ENGINEER RD 9 - FAIR STREET CARMEL, NY 10512 (914) 878 -6170 M 2 Re: 00 Dear Madam /Sir: �--(� Tu `t 3 Department of Health Review of Proposed Sewage Disposal System for property: Name: 4—o m-%d ce-a_ v Address: 12.E . 3 11 Town: Tax Map: Please be advised that an application for a Construction Permit relative to the construction of a sewage .system and /or well proposed for the captioned property has been made to the Putnam County 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 Mr. Hedges or Mr. Morris of the Health Department at 278 -6130. John H. Prentiss, P.E. RECEIVED 'BY: Address: Tax Map: 1. Name and Address of Applicant: John Servider 63- 85-Woodhaven Blvd. RR Rego Park NY 11374 2. NaTe of Project: Single Family Dwelling 3. Location T /V /C: T: Patterson -.Rt 311 4. Project Engineer: -John H. Prentiss, P.E. 5. Address: RD 9, Fair Street Carmel, NY 10512 License Number: 29206 -N.Y. Phone: 914- 878 -6170 0 7. Tyice of Project: X Private /Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Sutdivision Other (specify) _ Is th:s project subject to State Environment- al.Quality Review (SEAR)? Tv-,-e Status (Check One) Type I.. Exempt Type II. Unlisted X 8. Is a Craft EnvironmgntaY Impact Statement (DEIS) required? ............. No 9. HEs D_IS been completed and found acceptatle by Lead Agency? ......... 10. Name cf. Lead Agency', 111, is t 1is project in an area under the control of local • planning, zoning, NYS -DOT & or other officials, ordinances? ........ Building Inspection 12. If so, have plans been submitted to such authorities? Yes In 13. Has preliminary` approval been granted by such authorities? ProcessDate Granted: 4. Type cf Sewage Disposal System Discharge...... Surface Water X Ground Waters 5. If surface water discharge, what is the stream class designation ?........ 6. Waters index number, (surface) ........... ............................... 7. Is project located neap a public water supply system.? No 8. If yes., naime of water, supply Distance to water supply. ' Over 1 mile v9. Tr e near a puis senagc i�10? Or C r..... . No o. Namie c` se ac e syste��: Disiance 11--c sewage se's :e�im Omer 1 mile 1. Gat_ ctserved:ll ,1111g� 199 't 3. i,=me, of --nspe_to-: W. Hedges '' 600 4. Prcie:t de„isn flow (gallons p_. day) ...... ............................... AFPLICATT_ON FOR APPROVAL OF PLANS FOR A WASTEWATER GISPOSAL SYSTEM 1. Name and Address of Applicant: John Servider 63- 85-Woodhaven Blvd. RR Rego Park NY 11374 2. NaTe of Project: Single Family Dwelling 3. Location T /V /C: T: Patterson -.Rt 311 4. Project Engineer: -John H. Prentiss, P.E. 5. Address: RD 9, Fair Street Carmel, NY 10512 License Number: 29206 -N.Y. Phone: 914- 878 -6170 0 7. Tyice of Project: X Private /Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Sutdivision Other (specify) _ Is th:s project subject to State Environment- al.Quality Review (SEAR)? Tv-,-e Status (Check One) Type I.. Exempt Type II. Unlisted X 8. Is a Craft EnvironmgntaY Impact Statement (DEIS) required? ............. No 9. HEs D_IS been completed and found acceptatle by Lead Agency? ......... 10. Name cf. Lead Agency', 111, is t 1is project in an area under the control of local • planning, zoning, NYS -DOT & or other officials, ordinances? ........ Building Inspection 12. If so, have plans been submitted to such authorities? Yes In 13. Has preliminary` approval been granted by such authorities? ProcessDate Granted: 4. Type cf Sewage Disposal System Discharge...... Surface Water X Ground Waters 5. If surface water discharge, what is the stream class designation ?........ 6. Waters index number, (surface) ........... ............................... 7. Is project located neap a public water supply system.? No 8. If yes., naime of water, supply Distance to water supply. ' Over 1 mile v9. Tr e near a puis senagc i�10? Or C r..... . No o. Namie c` se ac e syste��: Disiance 11--c sewage se's :e�im Omer 1 mile 1. Gat_ ctserved:ll ,1111g� 199 't 3. i,=me, of --nspe_to-: W. Hedges '' 600 4. Prcie:t de„isn flow (gallons p_. day) ...... ............................... 2 '.5. is Sete Pollutant Discharge Eliminaticn System (SPDES) Permit required ?.. No '.6. Has SPDES Application been submitted,to local DEC Office? ............... 17. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... Yes 8. Wetland ID Number ........................ ............................... 9. Is Wetland Permit required? .............. ............................... No Has application been made to Town or Local DEC Office? .................. No 0. Does project require -a DEC Stream Disturbance Permit? ................... No 1. Is or was. project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial.activity? ........ YES or NO No 2. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ..............YES or NO DESCRIBE: No '. Is t ^ere a local master plan or file with the Town or Village? ........... Yes ':. Are community water, sewer facilities planned to be developed within 15 years? No i. Are any sewage disposal areas in excess of 15. slope? No 5. Tax Map ID Number ......................... ............................... 13. -3 -68 (Rt. 311) Approved Plans are to be returned to: Applicant _ X Engine; the application is signed by a person other than the applicant shown in Item 1, the >plication must be accompanied by a Letter of Authorization. Failure to comply with this •ovision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this fo , is true to the best of my knowledge and be ief. False staterrrents made herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of the Penal Law. - N.AIUr; L OP.:.L:AL TITLES: For wner.By: John H. Prentiss, P.E. (See authorization attached). I! ING .ADDRESS. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date 15 June 1993 Re: Property of John SPryider Located at Rnut-P all (T) Pattergnn Section 13. Block 3, Lot 68 Subdivision of Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize John H. Prentiss a duly licensed professional engineerXor registered architect (Indicate to apply -for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 1.45 or 147, Education Law, the Public Health Law, and the.Putnam County Sani- Cal r RD 9. Fair Street Address M M. PRENTISS, P.E. Carmel NY RD9'FAIR ST 911 -878 -6170 10512 , 914- 878 -6170 Telephone Very t Signed Rego Park, NY 11374 Town 718 - 459 -6630 Telephone 6C. N e d ' JOHN H. PRENTISS, P.E. CONSULTING ENGINEER RD 9 - FAIR STREET CARMEL, NY 10512 �L/n4 � -TUL. 4 U5 9'14 -Kc E;NOC.H G-Los; e Y ki�>, a 5TZ7-� / &L. Y, Jos-(7 Dear Madam /Sir: (914)878 -6170 Re: Department of Health Review of Proposed Sewage Disposal System for property: Name: A�xw De ! ,fN v t-c-L- Address:.LvY Town: SCfz, rx —�4-s r Tax Map: S-3 t_ Z_.0 Please be advised that an application for a. Construction Permit relative to the construction of a sewage system and /or well proposed for the captioned property has been made to the Putnam County 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 Mr. Hedges or Mr. Morris of the Health Department at 278 -6130. RECEIVED BY: Address: Tax Map: -5" - ,- / -- John H. Prentiss, P.E. i u h & O Wei I I Mar ie Ro eld rew5f -r N Y 4©S-O i Dear Madam /Sir: JOHN H. PRENTISS, P.E. CONSULTING ENGINEER RD 9.- FAIR STREET CARMEL, NY 10512 (914)878' -6170 juy t 9513 Re: Department of Health Review of Proposed Sewage Disposal System for property: Name: 4;7ne- 0, r oJA .,1, (� Address: � I-4; ,Y Z� Town: so Lc6i , e -qsC Tax Map: i— ,, -I - 20 Please be advised that an application for a Construction Permit relative to the construction of a sewage system and /or well proposed for the captioned property has been made to the Putnam County 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 Mr. Hedges or Mr. Morris of the Health Department at 278 -6130. RECEIVED BY: Address: Tax Map:5 John H. Prentiss, P.E. - AM o 1 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # 9 'WELL LOCATION Street Address r rS, Pte, �i Town Tax' Grid Number a 'fie , " ,WELL OWNER Name Mail ng Address ��13• yL J6ti !�. Sel r"V'4ar. 63�� kt.cc4 �, ,�� a . /� . j�lPrivate . ❑Public 'USE ' OF WELL 1 - primary .2 - .secondary. %RESIDENTIAL 0 BUSINESS ❑ INDUSTRIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP ❑ FARM O TEST /OBSERVATION U INSTITUTIONAL ❑ STAND -BY ❑ ABANDONED ❑ OTHER (specify O AMOUNT OF USE YIELD SOUGHT Fi;Ie gpm /# PEOPLE SERVED S :)r /EST. OF DAILY USAGE 4yo gal D REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION Q ADDITIONAL SUPPLY MNEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL' REASON FOR DRILLING -DETAILED. . AEASON FOR DRILLING y t-v, i I trn3 'WELL TYPE DRILLED []DRIVEN ®DUG ®GRAVEL. 0 OTHER S WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. '.WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES A 'NO ,NAHE OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: dtrPx 0,7e- LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED (J3b�,c?<69)/� MON SEPARATE SHEET �• Jdhn �t�ren�iss�PtE' , PERMIT TO CONSTRUCT A WATER WELL is permit to construct one water well as set forth above is granted under the provisions Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within irt3*. (30) days of the completion of water well construction, the applicant 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 attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. ing all well drilling operations, the applicant shall take appropriate action to assure that and all water or waste products from such well drilling operations be contained on this perty and in s h a manner as not to degrade or otherwise contaminate surface or groundwater. of Issue • �. 19� �,�-- �I;' � �- - of Expiration 19 Permit suing Official �- It is Non - Transferrable White copy: HD File Pink copy: Owner s Yellow copy: Bldg. Insp. Orange copy: Well Driller 1 1 ❑ u 30`0' �/ — �'a 10, -0„ j---/ _-- 590 00,000, 84 r a - s i S r t i i � • i C � �} ten X 4 i. a 1000 G ✓ A i �o?T'T'n vPtpa ! sort j Y UNGTIO- 00-\-73 1 � E r (LFO L iL 1 s I E 7' "4 PZa- 4 W/cA -PP 0? C IV 6—' o,.cTc.'r'wP,c ,I I s r ' j i i I r i E i V y r i x¢30 Im 5870 08' 36 "E T. 7 91 Oat- de- 0,16 01 ipproved conformance with tpplicable Rules and Beguliit:LonB of the CD lutnam County Health DejWtment... ' owl SO