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BOX 12
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01264
OWNER'S MWE
SITE IDMTION
ii " owe: I D,;l IFO 4 " me, DI 0 Z� IV is
1 "0 1 IDA V * I y- tic,•
-06
MhUaW ADDRESS
MGM INTERVIEW PM CaVlaint #
'Nam & Relationship (i.e,, ownerstenant, etc.)
DATE TYPE FACILITY
MOSED PHONE
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
NM: Repair must be in same location and of same type as original sewage disposal system.
Different location may ',require submittal of proposal from licensed professional engineer or
registered architect
Proposal approved Proposal Disapproved
Inspedtor's Signature & Title DRU
I
proposal approved with the following conditions:
1. Procurement of any Tom permits if applicaKe.
2. Submission of as built repair sketch in duplicate showing:
a. owner I s name.
b. Site Street Name; Town and Tax Map number.
c. Location of installed canponents tied to two fixed points (e.g.,,house corners).
Id. System description (e.g.,, 1250 gal. concrete septic tank,, three precast 61 disco. x 61 deep
drywells surr6mq�Wd by one foot + gravel).
e. Installer's name and number.
3. System repair to be'perfonned in accordance with the above proposal and conditions.
as owner, . or a rued, ent of owner agree to the above conditions.
SIGNUEIRE
MUS: Mite MM YeUcw (fin HE); Ark Lba2laut)
TITLE DM /2, OA7)
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New-York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
Cow r.
PCHD PERMIT #
WELL LOCATION
Street Address
3 W M
Town/Village/City Tax Grid Number
P fl S Ors lu Y• I Z
WELL OWNER
Name
iz 1 f t
Mailing Address
g &�,W 1-U 20 -
OAWk 3o&) j\j.y,(ZS-G3
rivate
O Public
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL
® BUSINESS
® INDUSTRIAL
®PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
❑AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
®ABANDONED
O.OTHER (specify
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE__gal
® REPLACE EXISTING SUPPLY O TEST /OBSERVATION Dl ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL
\,j Q ay.
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
®DRIVEN
ODUG C] GRAVEL
OOTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: NO
Lot No.
WATER-WELL CONTRACTOR: Name
Address:
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 & SOURCES OF CONTAMINATION PROVIDED
4 O ON SEPARATE SHEET `A —2 C
(I a e) 0 (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 Report 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 dril g operations be contained on this
property and in such a.manner as not to degrade or of er -' s contaminate surface or groundwater.
Date of Issue: 19 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