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BOX 25
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02994
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISIONi OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
picasi print oriype_ : , - 1,. ...e ... -.: o..._:.�� PCHD Permit # .f. ) q;p"
Well Location:
Street Address: Town/Village Tax Grid # -- 3 - 36
32- vt—=� amt 'tom"' v% AN,, \Ao-, .) Map Block Lot(s)
Well Owner:
Name:
Address: to5°N
Use of Well:
Residential Public Supply Air /Cond/Heat Pump Irrigation
1- primary
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought S' gpm # People Served Z• Est. of Daily Usage 150 gal.
Reason for
k Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
Low WATG2_
for Drilling
Well Type
_ Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No x
Is well located in a realty subdivision? ...................................... ............................... Yes No :4
Name of subdivision Lot No.
Water Well Contractor.VipgHAto A�IhiEr p t,,k Address :W6,P_C F_iZ
Is Public Water Supply available to site? .................................. ............................... Yes No K
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be r vit on separate sheet/plan.
Id
laatealr 1�..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 Department. During all well drilling operations, the applicant and/or
well driller shall 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 Public Health Director. Any revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam
County.
Date of Issue P; % C/ Permi
Date of Expiration . • Zoe Title:
Permit is Non- Transferrabl
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
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of 7Wr coUNTy c�sv_r� PUTNAAe eao
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SURVEY OF PROPERTY
FOR
liG.t/ET.4 �i
CURT A�TENBURGER
SITUATE IN THE
TOw,✓ Of PU%NA.N ✓,OLLiy
PvT.✓,eM COUNTY
NEW YORK
SCALE: 1"= 201
SURVEYED AS IN POSSESSION
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CERTIFIED TO:
Certifications hereon are valid for Bank,
SURVEYED: /L 2� /9Y7
Title Co. b Owners for this transaction
BROUGHT TO DATE
only. Certifications are not transferable to
•
subsequent Bank, Title Co. or Owners
BROUGHT TO DATE
All certifications hereon are valid for this
map and copies thereof only if said map
JOHN SALVATORE ROMEO
copies bear the impressed seal of the sur.
r-
Con.sulting Engineer & Land SurueyO
veyor whose signature appears hereon.
I NORTHRIDGE ROAD
is hereby certified that this survey was
PE"�KSKILL. N."It
Y.
prepared in accordance with the existing
Q� 'IQa is ep
Code of Practice for Land Surveys adopted
V
by the New York State Association of Pro.
P. E..& L. S. NYS LIC. NO. 027846
fessional Land Surveyors."
ENCROACHMENTS BELOW GRADE IF ANY NOT SHOWN
/.2£MLSSS ._s'NOwA/ I&X42,V BG.dG LQ*
/1- 212, 243 4 2.y PICT .S'NOA/A/ ON A
M.O0 6.v7'17-4 O "A44o of CAMP 400-011)
SA[D A✓AF L✓A't F/L E-O /.V I-W-- O�jiGC
of 7Wr coUNTy c�sv_r� PUTNAAe eao
,ZWA,WEL /t< y A3 Ae'l- A— 73e-
SURVEY OF PROPERTY
FOR
liG.t/ET.4 �i
CURT A�TENBURGER
SITUATE IN THE
TOw,✓ Of PU%NA.N ✓,OLLiy
PvT.✓,eM COUNTY
NEW YORK
SCALE: 1"= 201
SURVEYED AS IN POSSESSION