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02371
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TWO UNTY
DEPARTMENT OF HEALTH.
Division of Environmental Health Services
CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL '�,�L/ qq
PCHD PERMIT #VIA /,5CO _ n
WELL LOCATION
Street Address Town/Village/City Tax
14 Arbutus.Rd., Putnam Valley, NY_
Grid Number
WELL OWNER
Name Mailing Address
Joseph.Virilli,2452 Young Ave.,Bronx,NY 10469
QPrivate
0 Public
USE OF WELL
1 - primary
2- secondary
13 RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
0 ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
5 gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
EINEW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL
OTEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
DRIVEN
DDUG
11 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 P.F•Beal & Sons, Inc. AddressP.O.Box B.,Brewster,NY
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO
PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION ® N SEPARATE SHE T
i3 �
(date) ignature)
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 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 Department.
Date of Issue: 6c j� ��- 19
Jy AV
Date of Expiration: Gam, 19 j a ermit Issuing Ufprcial
Permit is Non- Transferrable White copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller