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02290
DEPARTMENT OF HEALTH
Division of Environmental Health Services
)LINTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO _CONSTRUCT A. HATER WELL
. -- °------ �-- s.- •.�.. ^....,- - �P CH it p F. RM T T -- -$1 A /lW-X�
WELL LOCATION
Street Address
�cc6 �'liat2
T Villag C y Tax Grid Number
37 S'o /l• l -X0
WELL OWNER
Name
Mailing
Address ,pat 4J.ee -v "04
G'(,Private
cl O Public
USE OF WELL
1 - primary
2- secondary_
I& RESIDENTIAL
O BUSINESS
O INDUSTRIAL
0 PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST/OBSERVATION
O INSTITUTIONAL O STAND -BY
0 ABANDONED
O OTHER (specify
Q
AMOUNT OF USE
YIELD SOUGHT
5 gpm /#
PEOPLE SERVED /EST. OF DAILY USAGE ,'� DD gal
REASON FOR
DRILLING
ONEW SUPPLY
®REPLACE EXISTING SUPPLY
O PROVIDE ADDITIONAL SUPPLY 0 TEST /OBSERVATION
0 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WMT �.
WELL TYPE
®DRILLED
DRIVEN
ODUG
11
GRAVEL
❑
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES K NO
IF WELL IS LOCATED IN A.REALTY. SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name
L[LI/1 W
Address:
1 "3w� v L 7
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _k__NO
NAME OF PUBLIC WATER SUPPLY:
DISTANCE TO PROPERTY FROM NEAREST
TOWN /VIL /CITY
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION &ION SEPARATE SHEET
(date)
(signatu e)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as s.et 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 s.hall:
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 D partment.
Date of Issue: 19__
Date of Expiration: Aa ✓ 19 Permit Issuing f cial
Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
CA,
MARIE VA USSo COU�
P.O. Box 38
PUT VALLEY NY 10579
91q;528_8094......
-`7
STATEMENT OF TAXES,
PUTNAM VALLEY i`CENT TAX BILL
SC1400L DISTRICT STATEMENT OF TA IES BILL N.O.
RETURN OffIRIE BALM TN MA PAYWMT
TOWNS OF CARMEL AND PLEASE
PUTNAM VALLEY" FISCAL 107/01/88
YEAR. 06/30/89
372800 CO
FR: FT- 110,00 W
'. DEPT-: 230s00
CLS-210, ROLL'�SECT-1 SCH-312803
L
R13 . AKE_ SEC, * C
HOUSE DOCK* K' -LOT 4,20 PT Of 4.21 ..l
:LAKE SHORE DRIVE-
00 04 34
I
9/01/8E
TOUN , OF
PUTNAM VALLEY'
PONAIC VALLEY. C 1304 0 13,4 0 149,004000 1,996.:6 5
ONE PAiMENT PAT THIS AMOUNT.— lt99665
I ilm. coLLE T TAXES AT THE JR HIG� scHooL FEIKSKILL
q PM.
TO. RD: 7HRU.FRI 10 00 AM TO 12 P" AND 1,00
TO. 2 01Y. p" s PT ONLY Oc SAME- HOURS .110 N AND FI; IDAY ONLY...-
.,.!PARTIAL PA NT DUE. SEP 159
PjkTJAlL' PAY'7i FIE
39*93
PENALTY FREE PERIOD FOR FULL PAYMENT FROM 09/01/8870 09/311/88
FOR FULL PAYMENTS FROM ID /D1 /8.9 101-31/89DD ONTEREST.
FOR PARTIAL PAYMENTS INCLUDING SERVICE CHARGE:
.. HALF $ 12019 29D.UENO LATER THAN j j14/ 15188
SECOND HALF $ 11018:29DUEBY 03/1!51 R9 TO Conn OF FINANCE...
OF 0�� ASSOTAINIM TO
BONTE MIAURTtE C: E SUZANNE.:-:,l�-� s 2-t6142 ti to --- W
RECEIVED FFMI'Tle STATE OF NEW
RD I SHORE DRIVE YORK DURNG . T"WiSCALVEM
LAKE El
PUINAM:- VALLEY MY 1057.9
MAXEDSTATE AID IS',; - # I ADDRESS CORRECTION
AND NOTIFY YOUR LOCAL ASSESSOR.
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