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: Division Of Environmental H%aA Services
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TWO COUNTY CENTER — CARMEL, N.Y..10512 (914) 225 -3641 _
APPLICATION TO CONSTRUCT A WATER WELL , e. ) • SrZ .
WELL TYPE DRILLED DRIVEN Q DUG._ ED GRAVEL OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: --
LOT NO.
WATER WELL CONTRACTOR: Name ffh e� tr Address
/ �t 4 e1,1 11q �i
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:. ___ YES / NOS • ' -
NAME OF PUBLIC -WATER SUPPLY: --" TOW -N /V /G
DISTANCE TO PROPERTY FROM NEAREST - WATER- -MAIN
- • . LOCATION SKETCH -•' &' ' SOURCES -OF -CONTAMINAT IUN
(date)
Onll
M77�
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 C unty Health Department.
Date of Issue: a 19
ermit Is ing Official
Permit:-i's-non-Transferrable
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k
AUDRESS.
WWNIVILLAGE/CI I Y tax GAiU Nun+6ER.
WELL LOCATION
�. >�
�()X .2 os P`tna (/a_ / /�-( N'% /03'7.9
WELL OWNER .
NAME •
dSr
AOORESS: .
,2 0 ELL
CB"PSIVAT(
❑ pUSLIC
USE OF WELL
RESIDENTIAL
O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP
O ABANOdNEO
1 - primary
❑ BUSINESS
❑ FARM - O TEST /OBSERVATION
❑ OTHER (specify)
2 - secondary
❑ 1NOUSTRIAL
❑ INSTITUTIONAL ❑ STAND -BY
O
.MOUNT OF-USE
YIELD SOUGHT
gpm. /NO. PEOPLE SERVED Z / EST.
OF DAILY USAGE '�d� gal.
REASON FOR
NEW SUPPLY
❑ PROVIDE ADDITIONAL SUPPLY
❑TEST /OBSERVATION
DRILLING
❑ gEPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
WELL TYPE DRILLED DRIVEN Q DUG._ ED GRAVEL OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: --
LOT NO.
WATER WELL CONTRACTOR: Name ffh e� tr Address
/ �t 4 e1,1 11q �i
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:. ___ YES / NOS • ' -
NAME OF PUBLIC -WATER SUPPLY: --" TOW -N /V /G
DISTANCE TO PROPERTY FROM NEAREST - WATER- -MAIN
- • . LOCATION SKETCH -•' &' ' SOURCES -OF -CONTAMINAT IUN
(date)
Onll
M77�
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 C unty Health Department.
Date of Issue: a 19
ermit Is ing Official
Permit:-i's-non-Transferrable
• 'r:•- _
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DAVIb".0. _9R.6tk
County Executive
DEPARTMENT OF HEALTH
bivision Of Environmental Health Services
RE: Proposed Well Construction
Application #-N
JOHN SIMM�bNS', M.D.
Deputy Commissioner
Dear Sir:
Review of the above captioned application has been completed.
Additional information or clarification is required as checked below:
l.- A detailed reason for drilling the well is required. Ashort narrative is
required. For what purpose will the well be'used,.i.e., drinking, lawn.
watering, etc.
2. Is the site presently served by:a well? .Explain_ Av zi Q
3.: Is the -site.presently served1by'a sewage-dispos''al system?.; Explain.
Icil
4. :Is -the,present structure to be reconstructed? • Expanded?, How?. PQ)
50 , A sketch ,showing -the'location of
the proposed well
-em--cn- - this .-parcel
—the existing'.-sewage sys�
- the existing house on this parcel
- existing sewage systems and wells on adjacent parcels within 200 feet of
the proposed well.
- all of the above is not provided.
6. The sketch provided is not sufficiently detailed. See #5 above.
Upon receipt of the above information this application will be considered
further°
very truly yours,
John Karell, Jr., P.E.
JK:mk Director Environmental Health Services
cc: Bldg. Insp.
F/L/jk-3
TWO. .COUNTY CENTER., 7 CARMEL, N.Y. 10512 (914) .225-3641
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