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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION 'OF ENVIRONMENTAL HEALTH SERVICES
r. APPLICATION TO ABANDON A WATER WELL
please print or type
PCHD PERMIT # 4w) 1 —Q
Well Location:
Street Address: TownNillage Tax Grid #
MaVLP Block / Lot(s)
Well Owner:
Name:
Address:
Well Type:
_ Drilled Driven Dug
Gravel Other
Depth Data:
Well;Depth ft
Static Water Level
ft Tate
Measured
Use of Well:
;XeI Residential Public Supply
Air /Cond/Heat Pump Abandoned
1- primary
Business Farm
Test/Observation Other (specify)
2- secondary
'Industrial Institutional
Standby
Water Well
Name: Address:
U4?y�
Contractor:
Reason For
Abandonment:
t✓
�' 442-11
Description of Work To Be Performed:
1611
Date Applicant Signature:
PERMIT
This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State, Sanitary Code and/or Part 75 of 10 NYCRR
and provided that: Within 30 :days of the completion of the abandonment of the water well, the applicant shall
submit to the Department a.certified statement that the information ,delineated on the application for this
permit has been completed:
0716t
Date A Issue 7ermit Issuing Official Title
White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WA -97
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINAl L R -N; MSN; .
Associate Commissioner of Health
ROBERT J. BONDI
County Executive
ROBERT MORRIS. YE
Director of Environmental Health
DEPARTMENT OF HEALTH
DRINKING AND RECREATIONAL WATER
Boyd Artesian Well Co., Inc.
c/o Henry Boyd
1054 Route 52
Carmel, NY 10512
Re: Proposed Well Heitmann & Heitmann
375 Dennytown Rd
(T) Putnam Valley
August 8, 2008
Dear Mr. Boyd:
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
stipulation:
1. 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:
Sincerely,
Mitchell D. Lee
Public Health Technician
110 OLD ROUTE 6, BUILDING 3 - CARMEL MY 10512
(845) 225 -5186 FAX (845) 225 -5418
please print or Woe
I
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO 'CONSTRUCT A WATER`WELL
PCHD re m iti,y
Well Location
Street Address: ': ' Town/Village: Tax Map #
�Q Block Lot(s)
ap
Well Owner:
Name:
Address: ,asya
Phone #:
-
6W�t' or
Use of Well:.
_12esidential _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 gpm # People Served Est. of Daily usage gal.
'Replace Existing Supply Test/Observation Additional Supply
Reason for Drilling
New Supply (new dwelling) Deepen Existing Well,
Detailed Reason
6.
for Drilling.
Well Type
Drilled Driven Gravel Other
Is well site subject to' flooding ? ....................................................... ..I............................. Yes No' C
_
Is well located in a realty subdivision? ........................................... ............................... Yes No Ne
Name of subdivision Lot No.
Water Well Contractor: Address:
Is Public Water Supply available.on site?
Name ;of Public Water Supply � �: 'S � i Tow�nNillage 4' � ? ` ' r•
n s )
Distance.ao'property.fron nearest water.,main. `
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Date:: Applicant Signature: 0;019a 01, A OW
PERMIT TU GUN51 RUG I A WA I EK WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code and 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 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:'
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 ground eater::,,.
APPROVED FOR CONSTRUCTION: This approval expires q�earsromthe date issued unless constructiq pf 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 Commissioner of Health. Any revision or alteration of the approved plan requires a
new permit. Well to be constructed by a water well driller certified by Putnam CAunty.
1
Date -of Issue 7 O`2� Permit Iss ing Offi "al:
Date of Expiration Ve7 lo5 ! Title: JI&5 � C..
Permit is Non- TransfbraBle
White copy - HD file; Yellow copy Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
Rev. 3/06
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