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02636
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914)
225 -3641
APPLICATION' TO' CONSTRUCT" "k— `WATER�`.WEDL
PCHD PERMIT #
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
Box 771, Peekskill o t Valley, 35 -3 -5
WELL OWNER
Name Ma Address Private
Peter & Irene Grosse, 60-iling 23 St. Felix Ave.,Glendale, W 11385 Public
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O BUSINESS O FARM 0 TEST /OBSERVATION 0 OTHER (specify,
O INDUSTRIAL O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED ? -4 /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
EINEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
isti e gate o �� t/
f� e- i�; Qnun,/ w ;& .b, C' ��s�i'� �. - T �' poi;
s,
4-e cri -e / .& P. Sp V Z-0 c
WELL TYPE
®DRILLED
ODRIVEN
ODUG
OGRAVEL
C] 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: NameMill Drilling, Inc. Address fttna» Av,Brewster, N1( 10509
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: n/a TOWN /VIL /CITY
"DISTANCE - TO "PROPERTY-FROM' WEAREST `WATER -MAIN : - _ _. _ _ .,.......... , _ _....... _.._..........._ _..;.
i
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION O ON SEPARATE SHEET
(date)
signature
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 pe it.
3. Submit a Well Completion Report on a form ided b he tnam County
Health Department.
Date of Issue 19 M7
e ssuin f i is
Date of Expiration: 19 <_-- �---�,
Permit is Non - Transferrable f White 0O = H.D. Fil
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
t1TIWVJ _. ... ,_ -_,. _._..._.,...._........ .. �W ... __ - ._.. ..,.� ..�..- ..
Putnam Ave. Brewster, N.Y. 10509
November 8th, 1990
Putnam County Department of Health
110 Old Rte. 6
Carmel., New York 105.12
Dear Sirs,
[9141279-5041
Please be a that the existing well .for
Peter & Irene GO as found and repaired on
October 2!�, 19901. `1El x efore, the Well Permit issued
by your Departmei M4-79 90) is not.needed.
The following 3urements for the existing well
rti r.�^
have been recorde v`� d' our files:
Well Depth - �t.
Water Level - U 5
GPM -5
We 11 Ti 1 e &Gover
10/25/90: ` I nst��l -1 GH07 Deep -Well Jet .Pump,
62- Gallon Diapf'r "n Pressure Tank,.
1 -1/4'" x l- 1 "astic Jet Lines set
at 95 ft .
Well Locati
Sharxl d : you h
hesitate to call
. nce re l y,
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