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Home My WebLink About2632DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -3 -22 BOX 22 oil r -r ,; 3�,, ,i J r� Cam ` - e, - �� - 6 � _ . . 02632 L "sl rN. ;.f1 j .,() 4 PUTNAM COUNTY DEPARTMENT OF HEALTH , i .0 o_ . •� ~� DIVISION OF ENVIRONMENTAL HEALTH SERVICES `i }�� Klt `y APPLICATION TO CONSTRUCT A WATER WELL i1 s I'' ' ' •A i L C C1 6 'TJ 42, print or type Well Location Street Address: Town/Village: Tax Map # ^� ^( Map�'Block Lot(s) Well Owner: Name: Ldr ss: .!� ,�� I o #• Use of Well: Residential _Public Supply Air /c nd /heat pum _ rrigation 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 for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ....................................................... ............................... Yes No _ Is well located in a realty subdivision? ........................................... ............................... Yes _ N Name of subdivision Lot No. Water Well Contractor: i ; Address• 1 ... Yes No Is Public Water Supply a ailable on site? .......................... _ _ Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. D3atb 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 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 Departmet 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 Commissioner of Health. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well c Date of Issue Date -of Expiration tr Permit is Non- Transf rable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Rev. 3/06 fell In 1054 Rte. 52 Carmel, N.Y. 10512 (845) 225-3196 CERTI IE[D (845) 225-8420 Nk LOIA X1®4 9L49f y P Uvl nn T LA, ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E. Director of Environmental Health Boyd Artesian Well Co., Inc. c/o Henry Boyd 1054 Route 52 Carmel, NY 10512 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Subject: Proposed Well Fromme 34 Wiccapee Rd (T) Putnam Valley November 14, 2014 Dear Mr. Boyd: MARYELLEN ODELL County Executive A field inspection was conducted on the above referenced lot by Vincent Perrin, Public Health Technician. The -appkation, to dri1.1_.a new well_is app.ovLd with he following stipul�ti�ns:._ _ '_._e 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) 808 -1390 ext.43131 if you have any questions. Sincerely, Vincent Perrin Public Health Technician cc: VP, file DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 PCHD PERMIT # —__::LS WELL LOCATION Street Address 3 y 1 GC 0 f7 Town/Village/City Tax Grid Number e-e. k/ �e a.n-) Val X A/ . of %9 WELL OWNER Name e Mailing Address Wrivate O Public E OF WELL - primary 2 - secondary GrRESIDENTIAL 0 BUSINESS ® INDUSTRIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION d INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O .A MOUNT OF USE YIELD SOUGHT ��r �~ gpm /# PEOPLE SERVED /EST. OF DAILY USAGE C/gal REASON FOR DRILLING O REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION Ll ADDITIONAL SUPPLY ❑ NEW SUPPLY NEW DWELLING DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING �.� e— '—' C2 V WELL TYPE ,DRILLED ®DRIVEN ®DUG ®GRAVEL. 0OTHER IS WELL SITE SUBJECT TO FLOODING? YES V" NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: A/0 Lot No. WATER WELL CONTRACTOR: Name dr(7"2 Q1 �(1 Q 2r5 o Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY:. TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER-MA-IN- LOCATION SKETCH &-SOURCES OF CONTAMINATION PROVIDED EPARATE SHEET (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 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 attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or 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. Date of Issue: /� 199 ----._ --G� Date of Expiration 19� Permit Issuing Officiff Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller . t i `� .... , . _ 4 �'--� �� _ Tea r,r k' • _ .. �. 1 tb j .. �=� V �j' ? p1 i� i. ! h> • .. :, 1, r,.3 :. � ;. f to --------- -_ �k i 1