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PUTNAM COUNTY DEPARTMENT OF HEALTH
D
° ® IVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
-• • please- prinfoftype .... _ ' PCHO Permit #' V1 /1 PJ —0 . . .
Well Location:
Street Address: Town/Village Tax Grid # Z.5 -,c ,?4
; Map/'4/714( Block Lot(s)
Well Owner:
Na me:
Address::
,54.4Q� d J� ��
J/
e4ow., l la)
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 0 gpm # People Served Est. of Daily Usage O gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
a 4-60
Ld
for Drilling
Well Type
�_ Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No �A _
Is well located in a realty subdivision? ...................................... ............................... Yes No X
Name of subdivision Lot No.
Water Well Contractor: &/3 wgltl es Address: e.054 KCi 5Z-
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 pro ded on separate sheet/plan.
Date: 4� �" 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 IPof th!6 ?' -i
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code an4rovild
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.
r
Date of Issue Permit Iss g Offi ial:
Date of Expiration Title:
Permit is Non- Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Own¢; Orange copy - Well driller
?V10 ?0 Se4
CaSin9
Well 't 6e ConS- rtjcteN w l Il T a M l ni A%Afl Form WP -97
1e.n V h of 8o
SHERLUTA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Boyd Artesian Well Co., Inc.
c/o Henry Boyd
1054 Route 52
Carmel, NY 10512
May 20, 2008
Dear Mr. Boyd:
ROBERT J. BOND[
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
Re: Proposed Well Boyd
13 Caldwell
(T) Patterson
A field inspection was conducted on the above referenced lot by Mitchell Lee, Public
Health Technician. The application to drill a new well is approved with the following
stipulations:
1.. Due to close proximity to the sub - surface treatment system, the proposed well is
to be coristruc>:ed with a minimum cas °nig length of 80 feet: _ ... ....... ...�.._ .____ ..._ ......_ . _. _ ._
2. A Well Completion Report (WC -97) shall be submitted no later than 30 days after
the well completion by the permittee.
Please contact me at (845) 225 -5186 ext.2233 if you have any questions.
cc �fi?1e,
Sincerely,
Mi chell D. Lee
Public Health Technician
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648
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