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Home My WebLink About0684DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23.11 -1 -43 I m� ' I I ■ ` i J . EL Ir Me *too] imam Moan PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # U 10 T Well Location: Street Address: o illage Tax Grid # ,� Map a Block / Lot(s) Well Owner: Name: OavAj v a TavcF Address: 1976&AorAA. v XD /! !lE Q 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 __5 gpm # People Served. -3_ Est. of Daily Usage gal. Reason for Replace Existing Supply - Test/Observation Additional Supply 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 Is well located in a realty subdivision? ...................................... ............................. .1. Yes No ✓ Name of subdivision Lot No. Water Well Contractor: T a, Address: — Is Public Water Supply available to site? .................................: ............................... Yes Name of Public Water Supply: '- Town/Village — Distance to property from nearest water main: ,VA Proposed well location & sources of contamina ' n to be vided on separate sheet/plan. % 2y 5 - - Date: Oi 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 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. 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 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 -f % --0 Permit Iss Offic' f!� Date of Expiration 22-f 7-0-1 Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT # AQ " 1 O '0 Well Location: Street Address: TownNillage Tax Grid # — ✓ Mapa3 # Block I Lot(s) Well Owner: Name: Address: 1/ /E Well Type: Drilled Driven ✓ Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump .!L Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Name: Address: Contractor: Reason For Abandonment: Description of Work To Be Performed: �. /� 14 GL4A1GovV fi�� ic/T p,c P6 l/JcGL 3 t t o.�/ kAA1 6r-A,111&EO WEGC /z �N t t /.�,A4/lE/J �y ,c��LdBO f%SSOCls -r�s L•4ST-' /:�ursc =0 �i�1 y` G' 1 /vr- 4 Date: Applicant 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. r / G- Date of Issue Permit Issui ffi al Title / White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT # r -C�CP Well Location: Street Address: TownNillage Tax Grid # Map,2.3 ii Block Lot(s) Well Owner: Name: Address: — vi Well Type: Drilled Driven V11*1 Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump -. Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Name: Address: Contractor: Reason For Abandonment: L Cv Description of Work To Be Performed: AaouvaoN��vr or- -- vJ :-L ,t2" nN PyA�v stir r� we4c P-1A /V ,�,� /4SSoc ii4T�s LRS r P..�"v�.sco 3�iy�a 6 . i Date: Applicant 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. 3 ` t? -0& Date of Issue . White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL RMIT # - 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. 3 -1� -0 Date of Issue White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 please print or type PCH D PE Well Location: Street Address: TownNillage Tax Grid # ati Map;73--i/ Block / Lot(s) y� Well Owner: Name: Address: Well Type: Drilled Driven Dug Gravel Other Depth Data: Well Depth ft I Static Water Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump ' Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Name: Address: Contractor: Reason For Abandonment: cCL W-V_ r Description of Work To Be Performed: 118AlN490N /44- /07-- O /- 12, tde4e- , -'2 d �V A W CNT /TcEO "11jazG "o 6,v , ,,&qo fL- �,4 7zD L.4,er .eew-s gw 3//y�oE i Date: 3 I -I ' Applicant Signature: i 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. 3 -1� -0 Date of Issue White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 ,OCIATES, L.L.P. - Planners March 15, 2006 Putnam County Department of Health 1 Geneva Road Brewster, NY 10509 ATTN: Michael Budzinski, P.E. Joseph J. Buschynski, P.E. Timothy S. Allen. P.E. Sabri Barisser, P.E. John P. McNamara. P.E. Robert A. B. Howe, B.S., Phys. RE: Well Permit/Abandonment King — Mt. View Rd — (T) Patterson Sheet 23.11 Block 1 Lot 43 Dear Mr. Budzinski: Please find attached the following items in support of the Well Permit application and three (3) Well Abandonment applications for Don King: • 4- copies of the Well Plan last revised 3/14/06 • 3 -Well Abandonment forms • Bank Check for $200.00 (Check # 109698) Pursuant to our phone conversations the following items have been addressed: • The neighboring well and septics have been added where appropriate, or notations added where known wells or septics are known to exist. • The three (3) existing wells have been labeled to identify them with their corresponding Well Abandonment application. • The well arc has been revised to extend 200 feet up hill per health department regulations. Thank you for your attention to this matter, and should you have any further comments or concerns please do not hesitate to contact me. Very truly yours, Richard D. Williams, Jr. RDW /bs Enclosures En D_ King Planning . Site Design . Environmental cc- Mill Pond Offices - 293 Route 100. Suite 203 • Somers, NY 10589 Phone: 914 - 277 -5805 - Fax: 914- 277 -8210 • E -Mail: bibbo@optonline.net A . / ^�`'a ' \ \ \\ 1 \\ ` \' \Sf�"•�, 1 ' �, '\ i 11 '1 1 \+ \ I \I I i i 1 / / `\ ' \'• If mho of SO4" \I\ I N77-131W E \ N 79 -SS , N 1 `� \\ \ 1 11 ` \ \ 1 I j I I _ Ia LTt - I , +• \ \ \ 1 \ 1 1 \ I ' E N 86_ J '32 7 o 4 • Aj I I I / / / / I I ` ` \ ` __ 1 1 I \ 1 / ` ` � \ \ + I I I I I ► 1 / I � .I I Sf4 I d - .' // � / � I fl __�.• -. � � I � � �`� —�� ````` � 1 I I I I I I 1 � I/ i � / \� 1 1 / i \ i� \ � � '• I � 1 � 1 1 1 1 1 1 1 1 1 I I` I I I $ \ I' I cs \ 1 � �$ ` z �` �� ` � � \ \ Iii 1\ , 1 1 ► I 1 1 1 �� I M li I spa 90 0 \ I I 568 5'3 I \ .46' II