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DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
\.5 APPLICATION TO CONSTRUCT -A WATER WELL
Y� PC`Hn PF.RMTT gl
WELL LOCATION
Street Address
ztl E-5[.4g-ti
Town/Village/City Tax Grid Number
WELL OWNER
Name Mailing Address
BRCIGE G�ic,Ci»�}n/ X3jel -W I-AAI& Aly
pQrivate
O Public
USE OF WELL
1 - primary
2- secondary
,'RESIDENTIAL
0 BUSINESS
0-INDUSTRIAL
OPUBLIC SUPPLY QAIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
0 INSTITUTIONAL O STAND, -BY
13ABANDONED
O OTHER (specify
0
AMOUNT OF .USE
YIELD SOUGHT
Jr gpm /# PEOPLE SERVED 5 /EST. OF DAILY USAGE 5-00gal
REASON FOR
DRILLING
13NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
O REPLACE EXISTING SUPPLY RDEEPEN EXISTING WELL
0 TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
QDRILLED
D
DRIVEN
DDUG
O
GRAVEL
®
OTHER
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 E•.L
�i/[� A�'�S /A�/ LJ�LLC!O..Si1/C: Address: �; /.% V /DS/ _
IS PUBLIC WATER.SUPPLY.AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTP -MCE- TO PROPERTY- FROM NEAREST -WATER MAIN :'
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION SEP T T
(date) (Ag ture)
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 appl-i cant s.hal l :
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.
Date of Issue: /-'/I e% 1/ % 19
Date of Expiration: 19_x% wit Issuing Official
Permit is Non - Transferrable White copy: H.D. File Yellow copy: Buildin g r
2/87 Pink Copy: Owner
Orange copy: Well Driller
PUTNAM COUNTY HEALTH DEEARTMW
DIVISION OF MWIRMENTAL HEALTH SERVICES
PROPOSAL FOR SEPOM DISPOSAL SYSTEM REPAIR
NAME PICNE
OWNE'R'S C-Z/: Z-� Z. h, .4-* -e
SITE LOCATION -S /-,--,v o r-- C/ TM#
MAILING ADDRESS
flnmffia_��
PERSON INTERVIEWED PCHD Canplaint #
Nam & Relationship (i.e, owner.tenant, etc.)
DATE TYPE FACILITY
e 2�-2
PROPOSED INSTALLER 2 PHONE �7 7<-
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 of proposal from licensed professional engineer or
registered architect.
1-:9 el-s-
-5
Proposal approved Proposal Disapproved
Inspector's Signature 4--Title
/7--
Proposal amroved with the followincr conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner Is name.
b. Site Street Nam, Town and Tax Map number.
(rd) location of installed carponents tied to two fixed point's (e.g.,house corners).
System description (e.g., 1250 gal. concrete septic tank,. three precast 61 diam. x 61 deep
d*-mils surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, . or epo t of owner agree to the above conditions.
SIGNATURE' TITLE DAM
. i 1R1: Xhite (PCHD); Yellcw (Tam ED; Pink (Aapliamt)