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02853
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 _(914) 225- 0310-.-
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APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # ld _603"_ Cl,
WELL LOCATION
Street Addr ss
4EM (C
�� +�e wn Villa a City Tax Grid Number
VAL (ad
WELL OWNER
Name /f
40CK
Mailing Address
SAwn e
Private
t Publ is
(SE OF WELL
1 - primary
2- secondary
RESIDENTIAL
9 BUSINESS
D INDUSTRIAL
O PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
O AIR /COND /HEAT PUMP
1 O TEST /OBSERVATION
O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE_�gal
E3 REPLACE EXISTING SUPPLY O TEST /OBSERVATION 12-ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING D DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DDRIVEN
®DUG
®
GRAVEL.
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
r Lot No.
WATER WELL CONTRACTOR: Name AADeR.SOW ,-41.4- � 1 ►� -�+NC� Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _)L__NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION
ON SEPARATE SHEET
(date)
PROVIDED p
(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 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 ontained on this
property and in such ma er as not to degrade or otherwis ont in at ur ac roundwater.
Date of Issue: /�4�9 A
Date of Expiration Ci " 19 Permi j ssuirig Official
Permit is Non - Transferrable White co : HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
Formerly Lawson
'
Now
or former /y Burkhardt
"
`Dirt
: WOfll5'out . -StolI a Ref. Wall ; "-X
-cul found
Pin 8
Cop
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Stave Rel. Wolf
589°3420aE
Drive / i
I %
on line
218.00'
\
Wall on fine
'"'WOII
Z X- cut found"
r11 fine
Wo /l 2.5ir -'. ::
3
J.0 in
h C y
i
on
W
� ..�
.,e i
c \ono '.
a v
�
°!�•
r •C
°Hemlock
O24
�0
open
�•I °'r'
1�
W I Porch
14' dory
2
i' i
,
/
iv,
' a� £lame
(�
it ``Qc �
Dwelling
a
� e
/
2
corm.
Porch
2 o,
Open
I
\\ 1'
e
l—
Area = 3/, 324 Sq. Ft.'
"
$ 1 Pin 6 Cop -� Pin 8 Cop1 \ r • / / titi
r
oSane
/
P,n 6 Cop
—Pin
�-
SURVEY OF PROPERTY
\I�
PREPARED FOR
x
WILL /AM M LOCKWOOD
A
SlrUArE IN rHE '
CA_
TOWN OF PUTNAM VALLEY
. �-
PUTNAM COUNTY
NEW YORK
Notes
SCALE /In. = 30 f1. OCTOBER 9 , 1987.
I.
Alteration of this document, jtxr ci9 by o licensed Land
' 1
"
P
Surveyor , is illegal.. r `
All rertrficntinn.c or;- valid tc�., his mnn and conies
We hereby cerli /y that the survey shown hereon
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