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25.41 -1 -33
BOX 10
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16 .
or
SITE LOCATION
OWNER'S NAME _
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
' 1
OFFICIAL USE ONLY
TM# . -, c{(- 1'3�
PHONE
PERSON INTERVIEWED PCHD Complaint #
Name & Kelationship (i.e., owner, tenant, etc.
DATE
PROPOSED INSTALLER
TYPE FACILITY tc�S
PHONE 6 q - L-7q' 60'C q
ADDRESS 'Aq S'c-11" C.,0 - Lh -I _ �� REGISTRATION# U4 L(
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submittal ittal of p/Jroposal from licensed �professional engineer or registered architect.
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,g�Ca --iAx, 1'fiv� e 7�i�+e —�rtr L A iZZ�•s Ci d
I. as owner; or reported_ agent of owlaer. agree .to - the - conditiQns..gtated_ on this form, - -
SIGNATURE TITLE
DATE
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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PUTNAM COUNTY DEPARTMENT OF HEAL p
DIVISION OF ENVIRONMENTAL HEALTH SERVI LielIf >q
APPLICATION TO CONSTRUCT A WATER WELL __ + .
please print or type PCHD Permit # W �p �p -' 0 LI
Well Location:
Street Address:
Town/Villaae ,,+ _a reNTax Grid #
7 Garland Road
Brewster `��"c"'�- Map 25.41 Block -1 Lot(s) -33
Well Owner:
Name:
Address:
Linda Ricciardelli
7 Garland Road, Brewster, NY 10509
Use of Well:
_ x 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 Est. of Daily Usage _gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new
dwelling) X eepen xisting We
Detailed Reason
Existing well is d
for Drilling
Well Type
X Drilled
Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? ...................................... ............................... Yes No
Name of subdivision
Lot No.
Water Well Contractor: P. F. Beal & Sons,
Inc. Address: 4 At[n Amm, Bmwster, NY imm
Is Public Water Supply available to 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 prow' e n et/plan.
Date _ Applicant Signature;
_ _ w_-
.Y _..� -: -_
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C/ %may T..flml /
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 re able for cause or may be
amended or modified when considered necessary by the Public Health Director An revision or alteration
of the approved plan requires a new permit. Well to be constructed by a wate 11 n by Putnam
County. //^��
Date of Issue 1 7 Permit Issu(pw&lci
Date of Expiration r/ r/ 61 Title:
Permit is Non - Transfe
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
e
P. F. BEAL &. SONS, INC. 61917
ARTESIAN WELLS - PUMPING EQUIPMENT
WATER CONDITIONING EQUIPMENT
BREWSTER, W 10509 768
DATE .a y !7 y
PAY
ORDER OF
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