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Home My WebLink About0627DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -2 -54 BOX 7 00627 IN . r r IN , I . r �, .. IN I I 6L L I ,� - ■ IM 00627 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New-York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL WELL LOCATION Street Address FArm ,Iqq . Town Village City r\.saL CiyN'al1 V Tax Grid Number WELL OWNER Name f}nn Can Mailing Address y99 Fra�m % !�Ir� -Key . rivate g/">S%O Public USE OF WELL 1 - primary 2 - secondary O RESIDENTIAL O BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP Q ABANDONED ❑ FARM Q TEST /OBSERVATION ❑ OTHER (specify O INSTITUTIONAL O STAND -BY %,Q� 1 L(-,, AMOUNT OF USE YIELD SOUGHT S gpm /# PEOPLE SERVED S /EST. C] REPLACE EXISTING SUPPLY g TEST /OBSERVATION 13 NEW SUPPLY NEW DWEL ING DEEPEN EXISTING WELL OF DAILY USAGE Sal Q ADDITIONAL SUPPLY E D2ILL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED aDRIVEN ODUG GRAVEL. 0OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name 60gC1 Pfr-h'_SI cLn wX'A (26. Address: 2 f 52 C►j►"n1 e�j IS PUBLIC WATER'SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH 6 SOURCES OF CONTAMINATION PROVIDED 911'-1 MOON SEPARATE SHEET rU m � d (date) (signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of 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 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 Re.p.Qrt on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or 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. Date of Issue:','�r//__:3' Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVUDAL ADDITION/REPAIR FORM SECTION A: GENERAL INFORMATION Name of Project �' '° y f`' �"� �)M .. TM# Year of Construction Size of Parcel SECTION 'B. TOPOGRAPHY (Please check all appropriate boxes) 1. 111illy ❑Rolling ❑Steep Slope Gentle Slope OFlat ' ence of wetland OLow.area subject to flooding Bodies of water 2. vid J � ; ❑Drainage ditches ❑Rock outcrop 3. Property lines evident? 4. Water courses exist on, or adjacent to parcel: 5. Existing individual wells within 200ft of the existing SSTS? YES O' L� s U SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS) 1.. Physical character of existing SSTS area. A. [level 0 'entle Slope ❑Steep slope B. ❑Well drained CIModerately well drained OSomewhat poorly drained OPoorly drained C. Area available for SSTS. (Primary & Reserve) /� OExtremel limited [Somewhat limited MAdequate ft x ft Y — D. INSPECTION Date S �3 r Inspector =� 0No evidence of failure OEvidence of failure []Evidence of seasonal failure _- - - - - - -- ------- - - -. -------------------------------- ------------ =_ %R ate- North) U-- C9� S , rn I 1 " c� k r HOUSE 'Ve (1) Indicate location of SSTS A. Size and type of septic tank gallons OTMetal Oconcrete []Plastic B. Type of absorption area 1. Fields ft. 2. Pits 3. Gallies ft. (2) Indicate setbacks, front street, backyard, and side yard dimensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams /wetlands) SECTION E. EXISTING `CATER SUPPLY CIPWS []Shared well Ofn-divi'dual well 17Drilled []Dug []Casing above ground COMMENTS REPAIRS ONLY: Status: As Built Inspection Required: As Built Submitted: As Built Inspection Done: Inspector: r PUTNAM COUNTY DEPARTMENT OF HEALTH • DIVISION OF ENVIRONMENTAL HEALTH SERVICES. INITIAL INDIVIDUAL ADDITION./, REPAIR FORM SECTION A. "GENERAL INFORMATION Name of Project i'�rr^ TM# Year of Construction Size of Parcel SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. Offilly [Xolling OSteep slope Mentle slope 11lat 2. UEvidence of wetlands Clow areas subject to flooding OBodes'of water'.' 1. hrainage ditches Mock outcrops _., YES. NO 3. Property lines evident? = O 4. Water courses exist on, or adjacent to parcel? l O 5. Existing individual wells within, 200ft of the'existing::SSTS? SECTION C.. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM (SSTS) 1. Physical character of existing SSTS area. A. CLvel L�Gentle slope 0S.teep slope B. DWell.drained 040derately well drained 0Some what poorly drained Opoorly drained C. Area available for SSTS. (Primary. & Reserve) O limited 0somewhat limited L JA'dequate ft x ft (1) . Indicate location of SS* A. Size and type of septid,tank gallons Metal O-Concrete Oplastic B.. `Type of absorption area I. Fields ft. 2. Pits 3. Gallies (2) Indid0d setbacks, front street, backyard, and side yard dimensions (3) Show location of well (4) Show1ocation.of driveway , (5) 1�ote,'.physical features (steep slopes- rock ootcrops,'. streams /wetlands) 70 1 ,ty��s �. IAL _......, P s .,. , _ ., ..; �...,_ . ,.... • ., ......... ENT.O�, HEALTH �. PUTNhivM1 COUPiY1`•DE R iN ri,._....,._....... •. _..__ .......,._.,..__ ..._..._........_.... _..........., E R HOUSE PLANS,PPP,J1�' .D..�p :._,.K.. _ _ :... ...... ...:...:....... .... ...,._.__...., _ M,.Cfl,. ___..._., ....... REDR00 U_ ti _ ONLY.;.... EDROO Signature & Title _ :._.. Dr .......... ... _......, P s .,. , _ ., ..; �...,_ . ,.... • ., ......... ENT.O�, HEALTH �. PUTNhivM1 COUPiY1`•DE R iN ri,._....,._....... •. _..__ .......,._.,..__ ..._..._........_.... _..........., E R HOUSE PLANS,PPP,J1�' .D..�p :._,.K.. _ _ :... ...... ...:...:....... .... ...,._.__...., _ M,.Cfl,. ___..._., ....... REDR00 U_ ti _ ONLY.;.... EDROO Signature & Title N I F- N 12° 41' 11 "E --f=-- IRON PIS PouNO M N I•� M M r m r Z aa� 0. 6 w93-1- L-L -O `( C7 IyN 1-7 1 0 C � 4•. `t- I STCN Mv/AI._ 79.10' �e .,-. GrS4MEI TmuF SMWr, m ` \ 1� W i ray CTfr• ) \\ avT.wusc - 11 a zo I � Z N \ � F� Is O'�� (I+ ,Slt °IV'o5 " ✓, a4' S /S�SS'38 "w – l vo�ANo FGNUE P ' -I I I 10 '7" W — 136 S2' 13'03'5 — �- r® C I q • i 1yN prP6 �� FpUNO O. II'S. o.la'w• n( I ?'05'25 "w N I P PR�STJA /,7G, 58 A IeBA = I t G, 00-7 $:F t 2.GGS AG.Y � –IpoN Ptre pqp N(T� t .6G" 1 ON LIMB 'li' Sol I� >F�AIeNt To ��1ce� �7riP:� -- - V MAP -KE-�-f- 6ZOAD SUIeV�Y OF IoKoreK-ry JOHN ANN f AOLUCCI S t-C uAII IN TOWN OF t°A-T`TI:tPSON 1°UTNAM CO., N.(- SGAIIE: 111= 50, AUGUS -T 12, Igg2 r P 16 7 Tn 'LUM(3IA Is QUITIES LMi ' -Eli y vl6L-( 'fl-fLG- SBI2I/tGa:3 �Arnc:lcA'Tl0►Jti IUDIGATZ h WE ZEjo4J 7}4Ai Ae4E,.( UAFi POE PIS 2ED I u Acme CaA1-rE VJfTN -ME C I5TIx. � Czc*- cr- PP.Ac"TIC.E. Cce LA,LIn '..om-E>Ki Azx. >Prz. L. -tlle_ LE.Iu' 4001-- t;PTF Ae4 cx.J.,I 0P' F 'S/�ICY�IAL ,Q0 SuevEyI �AICU SNAJ_L. 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AFL .t eil 971 C.A'Tl 01Y`s �4E P',E " ACE \1414 C, Gib MrS A.(ilf� A1Jp GoP1E'S Zl- IEPF_� d.1L`� IF �jd,l� MAJ Je BEAe -T)4E IAAPMt,4 � SEAL. -'C -rNE 'ttNC SIGI-14� APPeA,01, �- E o1J TT-- 0 -0 W >' u Sol I� >F�AIeNt To ��1ce� �7riP:� -- - V MAP -KE-�-f- 6ZOAD SUIeV�Y OF IoKoreK-ry JOHN ANN f AOLUCCI S t-C uAII IN TOWN OF t°A-T`TI:tPSON 1°UTNAM CO., N.(- SGAIIE: 111= 50, AUGUS -T 12, Igg2 r P 16 7 Tn 'LUM(3IA Is QUITIES LMi ' -Eli y vl6L-( 'fl-fLG- SBI2I/tGa:3 �Arnc:lcA'Tl0►Jti IUDIGATZ h WE ZEjo4J 7}4Ai Ae4E,.( UAFi POE PIS 2ED I u Acme CaA1-rE VJfTN -ME C I5TIx. � Czc*- cr- PP.Ac"TIC.E. Cce LA,LIn '..om-E>Ki Azx. >Prz. L. -tlle_ LE.Iu' 4001-- t;PTF Ae4 cx.J.,I 0P' F 'S/�ICY�IAL ,Q0 SuevEyI �AICU SNAJ_L. OUQ OLIL' iFrE FEP�ioLJ Gtr cINGYvI'Tr Su2V° ( If, [�EPkZ6Lj A!_10 J Fil�i BEJ �llls ZO 11{E TTTZE ..:DgIPkLLN A1J(� L1= 11C�IIJG 9ML,f C>" LAST EZ) ICE EC*J '--E2fn C7 1!'stT I CoI AOE: L.k3i' :A PEAZUL.F- -ro A[x-tT1ouAi_ 1�15TTT�IrIc>LJ�, oe. )BSE.Q UE KIT- cI IIJC`_. eS n 1 n - c: k.A- AL,lr- 7,97 A JF- d IDQ CZ A of-T 1011 -10'-MI', �le�/EY 1°`7 A v 101..A -no11 cr SEGT1011 # T z q ac 71}E J 1E1CJ '-(00' ST7ICTE LAkl IJ= AX-Pi rrs- SPOlu11. AFL .t eil 971 C.A'Tl 01Y`s �4E P',E " ACE \1414 C, Gib MrS A.(ilf� A1Jp GoP1E'S Zl- IEPF_� d.1L`� IF �jd,l� MAJ Je BEAe -T)4E IAAPMt,4 � SEAL. -'C -rNE 'ttNC SIGI-14� APPeA,01, �- E o1J TT-- 0 -0 DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 ADDITION APPLICATION= (RESIDENTIAL ONLY BRUCE R. FOLEY, R.S. Acting. Public Health Director STREET : /Fa& ,ti Jcj :0� (TOWN TX MAP # NAMEAIA& �Q�Gfi' PHONE /'3� PCHD PERMIT # 14 MAILING ADDRESS 1 �l�J Zo /fiJ /�-� .��7si%57< /4/l Description of Additionrr Number of existing bedrooms �_ Proposed number of bedrooms 0` Any addition which is considered a bedroom requires formal approval of plans (Construction Permit) prepared by a Professional Engineer or Registered Architec-L in accordance with applicable sections of the Putnam County Sanitary.Code. Please submit this form and the following to PUTNAM COUNTY HEALTH DEPARTMENT, 4 GENEVA ROAD, BREWSTER, NY 10509, Phone 273 -6130 with the .following information. 1. Certified Check for $100.00. 2. Sketch of existing floor plan (all living area including basement, if any) Non - professional drawing is acceptable. 3. Sketch of proposed floor plan. Non professional drawing is acceptable. 4. Copy of'survey showing well and septic locatan, to the best of your knowledge. Include date of installation if known. Include all wells and septic systems within 200 feet of property line. Any questions please contact this office. OFFICE USE Comments and /or conditions application August 1995 ,. ' w DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York. 10509 (914) 278 -6130 Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 Gentlemen: BRUCE R. FOLEY. KS, Acting Public Health Director Re: e15), Residence Tax Map 023 To�ti�n According to records maintained by the Town, the above noted dwelling IS _V IS NOT in compliance with Town code and the total number of bedrooms on record is This information has been obtained from: CERTIFICATE OF OCCUPANCY: ASSESSORS RECORD: BRUCE R FOLEY Public Health Director AnnMarie Conway . 499 Farm to Market Rd. Brewster, NY 10509 Dear Ms: Conway: 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 March 12, 1999 Re: Addition- Conway- Farm to Market Rd.. No Increases in Number of Bedrooms (T) Southeast Tax # 23 -2 -54 I have received and reviewed the plans for the proposed addition to the above - mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp form this Department dated March 12. 1999 The addition is approved with the following . conditions. 1. The total number of bedrooms must remain at Four without prior approval by this department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restrictors for shower heads and faucets, etc. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Southeast. If you have any questions, please contact me at your convenience. Very tru <urs,�'- William Hedges WH:kg Senior Public Health Sanitarian Cc:BI