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62.13 -1 -39
BOX 24
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DEPARTMENT OF HEALTH..
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT:#
WELL LOCATION
Street 44dress T
Tax Grid Number
WELL OWNER
Name M"* ling ddre
;, rivate
/o S 22 O Public
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL O PUBLIC SUPPLY O AIR /COND EAT PUMP 0 ABANDONED
BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify
0 INDUSTRIAL U INSTITUTIONAL O STAND -BY C3
AMOUNT OF USE
YIELD SOUGHT PEOPLE SERVED /EST. OF DAILY USAGE-S9 al
REASON FOR
DRILLING
L] REPLACE EXISTING SUPPLY O TEST /OBSERVATION XADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING L1 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
®DUG
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 h.�y,. Address ;1 Y �y �/ Ol�� � li
V i
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES __X,_NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE 73-PROPE%Tii -CRGr'i 14^BARE-:ST WATER MAIN.
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
❑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 shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the
Department attached to this permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
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 su h a manner as not to d gr de or otherwise conta n surface or groundwater.
c
Date of Issue: /r < rS 19
Date of Expiration 19 D Permit Issuing-Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
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(� C� ��
MARVIN O'DELL
Bldg. Inspector
JOHN MAHONEY
Deputy Zoning Inspector
4
.X
TOWN OF PUTNAM VALLEY-
BUILDING, ZONING, AND SANITARY DEPARTMENT
April 15, 1994
Putnam County Dept. of Health
4 Geneva Road
Brewster, N.Y. 10509
Att: Robert Morris
PUTNAM VALLEY, N.Y.
(914) 526 2377
BETTE STOCKINGER
Bldg. Dept. Clerk
Re: Proposed Well
(Zarcone) - 26 James Dr.
TM #62.13 -1 -39
Dear Mr. Morris:
The above noted property has been reviewed for the
construction of a new water well. �..
A well presently_ exists_. on this_ .parcel -near .the. -.
-- ri:crthwest-_- one-i "w Lici� Cpu Ldk�ly ns'ufi cient " __ _.... -.
yield for requirements.;
No record was found verifying the location of the
existing sanitary disposal system.
I enclose a copy of Survey dated, April 8, 1970.
Very truly yours,
MARVIN 0 DE
Building & Zoning Inspector
MO'D:es
enc.
"- 1: * , * ... **'***** ........ , 1-1 r LL I . . . .1. A-J ..... . . . . -- ---. - t.
AS SHOWN ON c) \A -\ \i
SITUATED .!.\I
FILED :N THE COUNTY CLERK' S, ..... MAP 140-W-)
GUARAr\j"rEE[0) T
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IN ACCOFRqXNCE'•WITH FAINIMUfA ,.;,rANI-)AR0S FOR TITIX SURVI-:'YS OF
15 -) CI ATI 0 N
I y f� T k. E� �LA 4 ITt;.,I,.
vr hereon 36,101 "All certifications h r on ar- v?lid
NYC LIC
..A
IZ DWARD G. MIFIALCZ0 1,!I, sul: VIE
for tlie,in-. -1) and copies thereof o.iiy
1
;-21�13-EJRJ�SHIRE RD. fl-I.Y. S . ...................
if said vi-tap or copies bear tie fill-
* \-?.r _ 11. — - 1 11
......................................................
11 prcss.-d seal of the surveyor
...........................................................
....................... sigoatul-0 Jl)pears horeon."
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